Organizational Principles to Guide and Deﬁne the Child Health Care System and/or Improve the Health of all
Joint Technical Report—Learning Disabilities, Dyslexia, and Vision abstract
Learning disabilities constitute a diverse group of disorders in which children who generally possess at least average intelligence have problems processing information or generating output. Their etiologies are multifactorial and reﬂect genetic inﬂuences and dysfunction of brain systems. Reading disability, or dyslexia, is the most common learning disability. It is a receptive language-based learning disability that is characterized by difﬁculties with decoding, ﬂuent word recognition, rapid automatic naming, and/or reading-comprehension skills. These difﬁculties typically result from a deﬁcit in the phonologic component of language that makes it difﬁcult to use the alphabetic code to decode the written word. Early recognition and referral to qualiﬁed professionals for evidence-based evaluations and treatments are necessary to achieve the best possible outcome. Because dyslexia is a language-based disorder, treatment should be directed at this etiology. Remedial programs should include speciﬁc instruction in decoding, ﬂuency training, vocabulary, and comprehension. Most programs include daily intensive individualized instruction that explicitly teaches phonemic awareness and the application of phonics. Vision problems can interfere with the process of reading, but children with dyslexia or related learning disabilities have the same visual function and ocular health as children without such conditions. Currently, there is inadequate scientiﬁc evidence to support the view that subtle eye or visual problems cause or increase the severity of learning disabilities. Because they are difﬁcult for the public to understand and for educators to treat, learning disabilities have spawned a wide variety of scientiﬁcally unsupported vision-based diagnostic and treatment procedures. Scientiﬁc evidence does not support the claims that visual training, muscle exercises, ocular pursuit-and-tracking exercises, behavioral/perceptual vision therapy, “training” glasses, prisms, and colored lenses and ﬁlters are effective direct or indirect treatments for learning disabilities. There is no valid evidence that children who participate in vision therapy are more responsive to educational instruction than children who do not participate. Pediatrics 2011;127:e818–e856
Sheryl M. Handler, MD, Walter M. Fierson, MD, and the SECTION ON OPHTHALMOLOGY AND COUNCIL ON CHILDREN WITH DISABILITIES, AMERICAN ACADEMY OF OPHTHALMOLOGY, AMERICAN ASSOCIATION FOR PEDIATRIC OPHTHALMOLOGY AND STRABISMUS, AND AMERICAN ASSOCIATION OF CERTIFIED ORTHOPTISTS
KEY WORDS learning disabilities, vision, dyslexia, ophthalmology, eye examination, vision therapy ABBREVIATIONS ADHD—attention-deﬁcit/hyperactivity disorder IDEA—Individuals With Disabilities Education Act ADA—Americans With Disabilities Act IEP—individualized education plan EBM—evidence-based medicine SSS—scotopic sensitivity syndrome This document is copyrighted and is property of the American Academy of Pediatrics and its Board of Directors. All authors have ﬁled conﬂict of interest statements with the American Academy of Pediatrics. Any conﬂicts have been resolved through a process approved by the Board of Directors. The American Academy of Pediatrics has neither solicited nor accepted any commercial involvement in the development of the content of this publication. The guidance in this report does not indicate an exclusive course of treatment or serve as a standard of medical care. Variations, taking into account individual circumstances, may be appropriate. This technical report supports the joint policy statement from the American Academy of Pediatrics, American Academy of Ophthalmology, American Academy of Pediatric Ophthalmology and Strabismus, and American Association of Certiﬁed Orthoptists titled “Learning Disabilities, Dyslexia, and Vision,” which is available at www.aap.org (direct link: www.aappolicy.org/cgi/reprint/pediatrics; 124/2/837.pdf) and www.aao.org(direct link: www.aao.org/about/ policy/upload/Learning-Disabilities-Dyslexia-Vision-2009.pdf). All technical reports from the American Academy of Pediatrics automatically expire 5 years after publication unless reafﬁrmed, revised, or retired at or before that time.
INTRODUCTION Reading is the complex process of extracting meaning from abstract written symbols. In modern societies, reading is the most important way to access information, and in today’s Western society, literacy is a prerequisite for success. In elementary school, a large amount of time and effort is devoted to the complicated process of learning to read. Because of the difﬁculties encountered in teaching some children to read, Congress mandated that the Eunice Kennedy Shriver National
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www.pediatrics.org/cgi/doi/10.1542/peds.2010-3670 doi:10.1542/peds.2010-3670 PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275). Copyright © 2011 by the American Academy of Pediatrics
FROM THE AMERICAN ACADEMY OF PEDIATRICS
Institute of Child Health and Human Development assemble a national panel of educators and scientists to research the optimal methods of teaching children to read. The 2000 report of the National Reading Panel, titled Teaching Children to Read: An Evidence-Based Assessment of the Scientiﬁc Research Literature on Reading and Its Implications for Reading Instruction,1 linked research ﬁndings with recommendations for speciﬁc approaches to teaching reading to all children. The panel concluded that existing evidence supported early explicit instruction in phonemic awareness, phonics-based reading programs, and guided oral reading to improve ﬂuency. Learning disabilities may interfere with children reaching their full potential. The inability to read and comprehend is a major obstacle to learning that may have long-term educational, social, and economic implications. Teaching children with reading difﬁculties is a challenge for the student, parents, and educators. Therefore, the causes and treatment of reading disorders have been the subject of considerable thought and study. This report discusses how we learn to read, the phonologic model, the recognition and treatment of reading difﬁculties, visual function and reading, the magnocellular deﬁcit theory, colored lenses and overlays, vision therapy, and the roles of the pediatrician and ophthalmologist.
angular gyrus immediately posterior to Wernicke’s area.4 Morgan,2,5 a general practitioner from England, published the ﬁrst case of a child with congenital word blindness in 1896. Subsequently, Hinshelwood turned his attention to both congenital and acquired word blindness. He credited the term “dyslexia” to Berlin.6 In 1917, he highlighted the potentially inherited aspect of reading disability. Hinshelwood estimated that 1 in 1000 students in elementary schools might have word blindness and postulated that the primary disability was in visual memory for words and letters. He strongly advocated intensive, individualized personal instruction.2,4 Beginning in the 1920s, Orton,2,7,8 a neuropsychiatrist, demonstrated a hereditary component for reading disabilities in children. His studies led to an expanded deﬁnition of reading disabilities that was much broader than Hinshelwood’s and included a graded series of all degrees of severity of disability. This more liberal deﬁnition increased the presumed prevalence to more than 10% of schoolchildren. IQ testing revealed that these children scored near or above average. In 1925, Orton attributed dyslexia to a problem in the visual system, which suggests that an apparent dysfunction from “mixed cerebral dominance” caused problems in visual perception and visual memory, characterized by perception of letters and words in reverse. The theory that visual dysfunction caused dyslexia led to a proliferation of training programs developed for visual-perceptual and/or visual-motor disabilities. In the 1960s, those prominent in developing and promoting these programs included Kephart, Frostig, Getman, Barsch, Dorman, and Delacato. Research into the programs revealed that, although these programs were sometimes effective in im-
proving perceptual and/or perceptualmotor development, they were ineffective in improving academic performance.9–12 Although the use of perceptual and perceptual-motor training by educators persisted for a time, by the mid-1980s its use had waned considerably. Attempts at improved understanding of dyslexia led to the rejection of the visual theories. This process began with a series of related studies that systematically evaluated traditional and widely accepted etiologic conceptualizations, such as Orton’s optical reversibility theory,7 Hermann’s spatial confusion theory,13 and other theories that implicated deﬁcits in visual processes, such as visualization, visual sequencing, and visual memory, as basic causes of reading difﬁculties.14,15 Although Orton attributed dyslexia to visual dysfunction, he was the ﬁrst to advocate intensive phonics instruction, sound-blending, and multisensory training.2,8 Orton’s work served as the stimulus for Gillingham and Stillman,16 who also emphasized multisensory training. Subsequently, the OrtonGillingham phonics techniques have served as the basis for many remediation programs. The International Dyslexia Society, formerly the Orton Dyslexia Society, provides information and resources to professionals and parents regarding reading disabilities. Learning Disabilities Learning disabilities constitute a diverse group of disorders in which children who generally possess at least average intelligence have problems processing information or generating output. Learning disabilities can affect neurocognitive processes and may manifest as an imperfect ability to listen, speak, read, spell, write, reason, concentrate, solve mathematical problems, or organize information. Some children may have associated difﬁcule819
History In 1877, Kussmal2,3 ﬁrst described a case of acquired word blindness in an adult alexic patient with a parietal lobe lesion. Hinshelwood,2,4 an ophthalmologist from Scotland, studied and described an adult with word blindness in 1895. In 1903, an autopsy of this patient revealed abnormalities in the left
PEDIATRICS Volume 127, Number 3, March 2011
ties with motor coordination. Learning difﬁculties can be associated with and complicated by attention-deﬁcit/hyperactivity disorder (ADHD),17,18 oppositional deﬁant disorder, obsessive compulsive disorder, anxiety, or depression.19 Problems in self-regulatory behaviors, social perception, and social interaction may exist with learning disabilities but do not, by themselves, constitute a learning disability. Although learning disabilities may occur concomitantly with other disabilities (eg, sensory impairment, intellectual disability, serious emotional disturbance) or with extrinsic inﬂuences (eg, cultural differences, insufﬁcient or inappropriate instruction), they are not the result of those conditions or inﬂuences.20 Results of recent studies suggest that approximately 20% of the population has some degree of a learning disability.21 In 2007, 2.7 million public school students (5.5% of all students in public schools) were identiﬁed as having learning disabilities and were eligible to receive educational assistance under the Individuals With Disabilities Education Act (IDEA).22 Speciﬁc learning disabilities include dyslexia (reading disability), dysgraphia (writing disability), and dyscalculia (mathematics disability). Although not included in the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision23 as a speciﬁc learning disability, nonverbal learning disability comprises difﬁculties with social interactions, interpersonal skills, nonverbal problemsolving, visuospatial skills, motor skills, reading comprehension, and mathematics and often coexists with strengths in verbal skills and with ﬂuent and accurate reading.23 Autism spectrum disorder, although not a speciﬁc learning disability, certainly affects learning, because people with autism have difﬁculties with verbal and nonverbal communication, social
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interactions, and motor function and may show inappropriate response to sensory information.23 Dyslexia Difﬁculties in reading are found in a diverse group of conditions that include dyslexia and secondary forms of reading difﬁculties caused by visual or hearing disorders, intellectual disability, experiential and/or instructional deﬁcits, and other problems.14,24–26 Dyslexia is deﬁned as a primary reading disorder that is separate from secondary forms.14,24–26 The terms “speciﬁc reading disability,” “reading disability,” “reading disorder,” and “dyslexia” are often used interchangeably in the literature.14 The term “dyslexia” is derived from Greek and means “difﬁculty with reading words.” Dyslexia is often unexpected in relation to the child’s other cognitive abilities. It is a receptive language-based learning disability that is characterized by difﬁculties with decoding, ﬂuent word recognition, and/or readingcomprehension skills. These difﬁculties typically result from a deﬁcit in the phonologic component of language that makes it difﬁcult to use the alphabetic code to decode the written word. Secondary consequences may include reduced reading experience that can impede growth of vocabulary, written expression, and background knowledge.27 A common misconception is that dyslexia is a problem of letter or word reversals. Reversals of letters or words and mirror writing occur normally in early readers and writers. Children with dyslexia are not unusually prone to reversals. Although they do occur, reversal of letters or words, or mirror writing, is not included in the deﬁnition of dyslexia.14,28,29 People with dyslexia may be very creative and bright. In many cases, their high-level thinking is unaffected, and they may be gifted in mathematics, science, the arts, or even in unexpected areas such
as writing.28 People with dyslexia read slowly, but not all people who read slowly have dyslexia. Approximately 80% of people with learning disabilities have dyslexia, which makes it the most common learning disability.24,25,30–35 Depending on the deﬁnition chosen, the prevalence of reading disability is approximately 5% to 20% of school-aged children in the United States.21,24,31,34 Reading disabilities seem to affect males slightly more than females,36–38 although schools identify boys with them twice as often as girls.22,31 Both environmental and genetic inﬂuences affect the expression of dyslexia.39 Dyslexia has been identiﬁed as having a strong genetic basis.14,24–26,30,31,40,41 Approximately 40% of siblings, children, or parents of an affected person will have dyslexia. Although dyslexia may be inherited, it may also exist in the absence of a family history. Results of family and twin studies have suggested that 50% of the problems in performance can be accounted for by heritable factors; environmental inﬂuences are greater in children with lower IQ scores.42 Reading ability and reading disability occur along a continuum; reading disability is represented within the lower tail of a normal bell-shaped distribution of reading ability.21 The lower tail is actually composed of reading difﬁculties from both primary dyslexia and secondary causes. Dyslexia is a lifelong condition that varies in degrees of severity. Most children with reading disabilities have relatively mild reading disabilities, and a smaller number of them have more severe reading disabilities.21,30 Because reading skills occur on a continuum with no clear distinction between typical readers and readers with dyslexia, some experts assert that the term “dyslexia” should be reserved for the 2% to 5% with the most severe reading deﬁcits.43
35 In the later grades. tiring. low self-conﬁdence. more than 88% of these children display similar difﬁculties at the end of 4th grade. Number 3. 24–26. when the word “cat” is spoken aloud.50 Seventy-four percent of those children identiﬁed in 3rd grade as reading disabled will remain so in the 10th grade. Decoding breaks the code receptively and encoding (spelling) puts it back together expressively.FROM THE AMERICAN ACADEMY OF PEDIATRICS
Dyslexia occurs at all levels of intelligence and is a persistent problem that does not represent a transient developmental lag. 28–31. This shame may cause a loss of motivation to learn to read that can further compound the situation.34.34 English uses an alphabetic system in which each letter is a symbol that is an abstract building block of that language’s phonemes (sounds).” which makes oral communication much more efﬁcient.1.39 Students who cannot read well read less. March 2011
. writing.60 The phonemic complexity of a language corresponds to the prevalence of dyslexia.30. The vocabularies and concept knowledge of children who read less will plateau as their reading peers improve. whereas approximately 35% of students with disorders of attention also have reading disability.14. “pet” and “bet” are distinguished by the sounds of their initial consonant.35. Disorders of written expression can manifest themselves as difﬁculty with spelling and problems putting thoughts on paper. is an acquired skill. Dysgraphia is a learning disability that affects writing abilities. an artiﬁcially designed use of abstract symbols to represent language.43. 34. Dysgraphia is the learning disability that most frequently cooccurs with dyslexia because of their directly related phonemic base. Over time.39 The ﬂuency deﬁcit is problem*Refs 14.55 To make normal conversation possible.35. and energy on the task. history. A written word like “cat” has 3 lettersound units.55 Phonologic awareness is the basis for scaffolding written language onto oral language. the 2 disorders are distinct and separable.19. changing the “p” to “b” changes the meaning of the word. Untreated or poorly treated dyslexia may lead to frustration. when children switch from learning to read to reading to learn. and difﬁcult. who are expected to read increasingly sophisticated texts.30. but they have a persistent problem with ﬂuency and continue to read slowly and not automatically throughout their lives. Phonologic Model Currently.54 However. concentration. 20. which points to the linguistic origin of dyslexia. the most accepted model for the acquisition of the ability to read is the phonologic model. whereas phonics is the un-
derstanding that segmented units of speech can be represented by printed forms. Children who get off to a poor start in reading rarely catch up on their own. Dysgraphia can also manifest itself as difﬁculty with writing motor coordination or poor handwriting.44. English is a phonemically complex language in which the 26 letters of the alphabet create 44 sounds or phonemes in approximately 70 letter combinations. For example.57–59 Oral language acquisition is preprogrammed into human development.19. 35. Oral language development has been found to play a critical role in learning to read.55 Phonemes are the speech sounds that enable us to tell 1 word from another. mathematics.51 Readers with dyslexia must expend more attention. and poor self-esteem.53 Many children with reading disability are observed to grow ashamed as they struggle with skills that their classmates master easily. not 3. With interventions. a drive for expression through organized vocalization seems innate to infant development. thus. which substantially increases the risk of developing psychological and emotional problems. good readers and poor readers without intervention tend to maintain their relative positions along the spectrum of reading ability.56 Coarticulation is the merging and overlapping of sounds into a sound “bundle. reading-impaired children are prevented from fully exploring science. although speciﬁc languages need to be acquired. people with dyslexia may learn to read accurately.52 The consequences of a slow start in reading become monumental as they accumulate exponentially over time. although the ear hears only 1 sound. 8 to 10 phonemes per second are strung together and blended so thoroughly that it is often impossible to separate them. Phonologic awareness is the sensitivity to the sound structure of oral speech and phonemic awareness is the understanding that speech can be segmented or broken into individual sounds that signal differences in meaning.33. On the other hand.* Children with poor oral language skills in kindergarten often become poor readers. which makes reading unpleasant. and the wealth of information that is presented in print. literature.24.29 Manifestations of dyslexia are often worse in English because of the greater number of inconsistencies and exceptions within the English lane821
PEDIATRICS Volume 127.32. and 44– 49.
atic for older children. The spelling deﬁcits in dysgraphia may be oral and/or written.30 Approximately 15% of students with reading disability also have ADHD. Both inaccurate reading and diminished reading practice cause slow growth of ﬂuent wordidentiﬁcation skills and vocabulary growth. A poor reader in 1st grade will almost invariably stay a poor reader. Lost practice opportunities make it difﬁcult to acquire even average levels of reading ﬂuency.
numbers. 46– 49. 24.† The ability to learn to decode print is determined primarily by phonologic skills such as phonologic awareness.14. other children can show comprehension difﬁculties in the absence of wordrecognition problems. 55. and verbal memory. any or all of these problems can interfere with the ultimate purpose of reading. Children with more severe forms of dyslexia may have a second deﬁcit in rapid automatic naming that causes slow naming of letters. Thus. effortlessly. facility in alphabetic mapping. Poor decoders are stuck on the task of trying to sound out words to make sense of the text. because phonemes are not separated in speech. 24–26.32–34. reading speed and ﬂuency become critical factors in ensuring that children gain comprehension. the fewer the new words to which the child is exposed. which means that the problem is located physically in the brain. and comprehension and requires adequate memory and sustained attention.24.72 Fluent reading requires automatic phonemic decoding and word recognition. An inexperienced reader will use the phonetic method to sound out most words and consequently will read slowly.14 The reader with dyslexia experiences difﬁculty in decoding and identifying words because of a speciﬁc impairment in the neural representation. memory. which creates a double deﬁcit. which is comprehension. is the ability to sound out words. Decoding. 30–35.24. retrieval.‡ Children with dyslexia often experience even more difﬁculty with
†Refs 1. or word attack. because children must be aware of the sound structure in spoken language and then break the alphabetic code to acquire the sound/ symbol connection. Vocabulary acquisition in a child with dyslexia often may not keep pace with that of a child’s peers. Word recognition is the ability to read words without sounding them out.31–34.25. name encoding and retrieval.52 The next task for the beginning reader is to move from the early phases of “sounding out” words to the more skilled phase in which word recognition occurs almost instantly. 25. and coding of phonemes. vocabulary. although not all children with poor spelling skills have dyslexia. ‡Refs 1. however.30–35 Thus. Fluency is the ability to read connected text with expression rapidly.guage. Poor decoding is the core characteristic of poor reading.70 Some children with reading difﬁculties also experience a deﬁcit in orthographic skills. 46– 49. 39. Most people with dyslexia have a neurobiological deﬁcit in the processing of the sound structure of language.14 Learning to read and write is a complex process that requires active learning.
spelling (dysgraphia) because of imperfectly stored representations of words. because the less a child reads.34 Neurobiology Dyslexia is currently believed to be neurobiological in origin. but dyslexia is conﬁned neither to the United States nor to English speakers. and 64.24. Average readers require 4 to 14 exposures to a word before it becomes a sight word.14. it is difﬁcult to apply general intelligence and reasoning. although these skills may improve with development. The foundation for reading is decoding.71 A child must ﬁrst accurately decode a word before it can be read ﬂuently. and pictures. and automatically with little conscious attention to decoding. Developing this awareness is not automatic.15. inadequate vocabulary. 43. ﬂuency. and syntax to the reading endeavor to obtain comprehension.31. There is strong scientiﬁc evidence that supports the neurobiological basis for the phonologic-coding–
FROM THE AMERICAN ACADEMY OF PEDIATRICS
. 15.34 Comprehension is impaired without efﬁcient automatic word-recognition skills. 31–34.33. storage. smoothly. children do not have enough attentional capacity and cognitive energy to remember what they have read.55 If reading is slow and labored because of decoding difﬁculties and requires a large portion of their available conscious attention.64 Although the ability to read words accu-
rately is a necessary skill.52 Experienced readers use the whole-word method and will quickly recognize most words as individual units.25. which are deﬁned as difﬁculties with letter/ number orientation recognition and memory. called a phonemic deﬁcit.64 Current theory maintains that the deﬁcit in lower-order phonologic linguistic decoding function blocks access to the usually intact higher-order cognitive and linguistic functions. Unless the child can convert the printed characters into the phonetic code.32. verbal reasoning. Reading is more difﬁcult than speaking. the sounds must be broken apart. 14.25.33 whereas students with learning disabilities may need up to 40 exposures. these letters remain a mystery of lines and circles that are devoid of linguistic meaning.34 In some cases. attention. much less relate the ideas to their own background knowledge. teaching reading is rocket science! Reading comprises decoding. To decode a written word. Fluency forms the bridge between decoding and comprehension. and limitations in background knowledge also can cause readingcomprehension difﬁculties. 20.1. and 62– 65.34 According to Moats61 and the American Federation of Teachers. No ﬂuent reader uses phonics routinely.66– 69 Other children with severe forms of dyslexia may have problems with their short-term working memory or attention or an additional comprehension deﬁcit. which impairs decoding and prevents word identiﬁcation. 60. In addition to decoding deﬁciencies.
and the left occipitotemporal area.¶ These studies have demonstrated that dyslexia is an abnormality in the wordanalysis pathways of the brain that interferes with its ability to convert
§Refs 14. which serves word analysis. 48. and 73– 85.34. Teachers are in a position to identify reading problems before they progress significantly. 49. 31.
written words into spoken words. Functional MRI studies have also shown brain plasticity in that the dyslexia-speciﬁc brain-activation proﬁle improves after successful evidence-based phonologic remedial intervention. naming.86– 88 Functional MRI and positron emission tomography (PET) scans measure changes in metabolic activity and blood ﬂow during cognitive tasks in speciﬁc brain regions. on the other hand. 48.90 Because dyslexia is both familial and heritable.33 At all grade levels. which is involved in word-form and ﬂuent reading. and silent reading. Recent genetic-linkage studies have identiﬁed many loci at which dyslexia-related genes are encoded. and 73– 85. preterm birth. Early identiﬁcation of children in early grades who are showing delays or difﬁculties should be a high priority for elementary school teachers. handwriting. not a result of poor reading experience. reading. 25. or developmental delay. low birth weight. a child with reading disabilities may show difﬁculty with remembering words. 46.34. and brain development. In people with dyslexia. which is associated with lexical retrieval. 46. In elementary school. or writing speed. and the posterior inferior temporal cortex. in many cases. 66. learning disabilities are not discovered until children experience academic difﬁculties in elementary school. axonal growth. and MRI ﬁndings in languagerelated areas have been observed in the brains of patients with dyslexia.58.14. 30.91 However. language.81 Many parents who had noticed that their child was exhibiting learning difﬁculties waited a year or more before acknowledging that their child might have a problem and seeking assistance.25. 48. including the absence of the normal asymmetry in the language areas of the brain and similar volume in the left and right planum temporale. 24. cognitive difﬁculties.89
exposure to drugs or alcohol.24. 39.35. 40. Number 3.80. March 2011
. teachers must understand the course and the role of instruction in optimizing literacy development. and 73– 85. Neuroanatomical changes. Children with dyslexia.81. Teachers need to have a strong understanding of the result of research in reading theory and practice to become well versed in reading development and assessment. 30. affected younger siblings can often be identiﬁed earlier.48. It is postulated that this abnormality is causal. use different areas of the brain when reading. People with dyslexia have demonstrated a dysfunction in the lefthemisphere posterior reading systems and have shown compensatory use of the inferior frontal gyri of both hemispheres and the right occipitotemporal word-form area. 40. 43. but its symptom proﬁle changes over time. evaluation for learning disabilities should be considered for all children who present with school difﬁe823
RECOGNITION AND TREATMENT
Dyslexia is a disorder that affects people of all ages. learning rhymes. A child should be observed for early indications of dyslexia if he or she has a family history of learning disabilities or has a history of other factors that may be predictive of learning disabilities including hearing. Young children are able to undergo diffusion tensor imaging. Four candidate genes have been implicated in neural migration. the left planum temporale is larger. microarchitectural distortion. 25. 34. 34. or speech problems.§ Both anatomical and brain-imagery studies have revealed differences in the way the brain of a person with dyslexia develops and functions.89 These brain changes seem to cause phonologic and auditory processing abnormalities. fetal
PEDIATRICS Volume 127. 2 areas in the posterior brain regions—the parietal temporal region. functional MRI and PET-scan studies have shown that reading takes place predominantly in lefthemisphere sites including the inferior frontal (Broca) area. severe head injuries. Refs 14.53 White-matter pathways of the brain may be characterized by diffusion tensor imaging that provides a quantitative index of the organization of large myelinated axons that constitute the long-range connections of brain networks. It is not in the child’s best interest to “wait and see” or hope that the child will “grow out of” his or her problems. spelling. 49. 66.62. may be an early indication of dyslexia.FROM THE AMERICAN ACADEMY OF PEDIATRICS
deﬁcit theory of dyslexia. normally. 66. 46. ¶Refs 24. After initial school interventions have been unsuccessful. In typical readers. and early evaluation and intervention should be considered.28 An early history of language difﬁculties such as delay or difﬁculty in developing speech and language. infections of the central nervous system. 31. 24. 25.81 Parents or teachers may detect early warning signs of learning difﬁculties in preschool-aged children. 40. 39. which is associated with articulation. 49.85 White-matter abnormalities have also been detected in association with dyslexia. whitematter organization seems to be weaker in the left posterior brain region and seems to project too weakly within the primary reading pathways of the linguistic left hemisphere and too strongly between hemispheres. 30–35.24. or recognizing letters and sound/symbol connections.
30. 43. 14.51 Gains are maintained for at least 1 or 2 years by approximately 50% of children after they return to the school’s standard curriculum. 35. In early elementary school.35 Comprehensive beginning reading instruction is the best educational prevention for reading problems.34.34 Poor comprehension skills also persist and will impair the ability to learn in general. but it is not diagnosed in some students until later during middle or high school. Assessments for difﬁculties with alphabet recognition. 47. 20.92 Educational experts indicate that reading aloud to children is the single most important activity for parents and caregivers to do to prepare children to learn to read. Deﬁcits in phonologic coding continue to characterize readers with dyslexia even in adolescence and adulthood. some children compensate by using other strengths until the educational demands increase and make the reading disability more evident. The best current approach to the problem of reading failure is to allocate resources for prevention and early identiﬁcation. Results of longitudinal studies have shown that when intervention is delayed until 3rd grade or 9 years of age (the average age at which these children receive services). 33. 54. 25. The IDEA guarantees each child a free. Late emerging reading disabilities often go undetected in schools. 65. 14. These children who retain their beneﬁts improve from year to year. semantic. including learning disabilities. they will have signiﬁcantly fewer problems in learning to read on grade level than do children who are not identiﬁed or helped until 3rd grade.
FROM THE AMERICAN ACADEMY OF PEDIATRICS
. 60. a combination of poor word recognition and poor comprehension skills. 58. 60. 39. and 93.
reading disabled after 2nd grade rarely catch up to their peers.96 People with a physical or mental impairment that substantially restricts 1 or more major life activities are eligible for services under Section
††Refs 14. 65.34 Older children and adults may learn to read words accurately. 60. then approximately 74% of these children will continue to have difﬁculties learning to read through high school.# Prevention and early phonologic awareness intervention programs in kindergarten through 2nd grade can increase reading skills in many poor readers to average reading levels.43. and related services. or solely attributable to poor comprehension skills. even if reading difﬁculty is not the chief complaint. Difﬁculties in early reading may be caused by experiential and instructional deﬁcits in addition to primary dyslexia.35 Experiential risk factors include being raised in a high-poverty environment or in a home in which English is the second language or having limited exposure to oral or written language. 55.94 If readingimpaired children receive effective phonologic training in kindergarten and 1st grade. Approximately 10% of children with dyslexia have good word-reading skills but have poor listening and readingcomprehension skills. Section 504 of the Rehabilitation Act. Some children enter school with experiential deﬁcits in oral language skills and general knowledge as well as delayed phonologic skills. 35. 24. 32–35. 19. and the Americans With Disabilities Act (ADA) deﬁne the rights of students with dyslexia and other speciﬁc learning disabilities. 24. differentiate them from children with true dyslexia. the time and expense of doing so is enormous.35 In the elementary grades. and 95. The beneﬁcial effects of early identiﬁcation and intervention are apparent in many studies. and syntactic difﬁculties.** Children identiﬁed as
#Refs 1. 64. 43.95–98 The IDEA deﬁnes a child with a disability as someone who has any of 13 disabling conditions. reading screening should be performed yearly and early in the school year. Poor comprehension skills are often attributable to working-memory. and adding oral reading ﬂuency in 2nd grade can predict many of those who will have difﬁculty learning to read.†† Although older children and adults can be taught to read. but they will not be as ﬂu88.6% to 6%. and provide proper remediation for them. appropriate public education tailored to his or her individual needs and allows parents to request a formal educational evaluation by the school district to determine if a child has a disability and qualiﬁes for special education and related services. but they do not further catch up to typical readers. 32. 34. 30. transition planning.33. Torgesen reviewed many studies on early intervention and found that when intervention began in the 1st grade.57. The IDEA also provides funding for special education services.34 Parents should read aloud to their children to help develop language skills beginning as early as 6 months of age. The IDEA.43 Waiting for failure decreases the chances of interventional success.culties. It allows parental access to all meetings and paperwork. and who need special education and related services because of the disability.53 Dyslexia is most often identiﬁed in the primary grades. 90.
ent or automatic. when more complex reading and writing skills are required. 64. 54. It is important to recognize these children. **Refs 1. 41. and 65. Reading problems diagnosed in the 4th grade or beyond may be secondary to poor word recognition.93 adding word identiﬁcation ﬂuency in 1st grade. the expected incidence of reading disability of 12% to 18% was reduced substantially to 1. phonemic awareness and rapid naming in kindergarten. which results in a slower reading rate.
observation of the child in the classroom. the federal law that governs special education. information-processing abilities. Children with ADHD who do not need more comprehensive special education support also are frequently served under this law. The ADA protects people who have a physical or mental impairment that restricts 1 or more major life activities from discrimination. The assesse825
.99 As a result. Comprehensive evaluation in all areas of the suspect disability should be conducted. The assessment techniques should be evidence based. social. developmental. there is an emerging consensus among researchers and clinicians that the dependence
on a discrepancy between IQ and reading achievement for a diagnosis of dyslexia has outlived its usefulness except in limited circumstances. and evaluation of test data. the child will be placed diPEDIATRICS Volume 127. and educational histories.105 A comprehensive evaluation is necessary to determine the appropriate diagnosis for children who present with reading weaknesses. school psychologist. and be protected from discrimination. academic skills.103 Although many schools still use a discrepancy formula to qualify students for special education. In the RTI method.104 There is no single standardized test used to make the diagnosis of dyslexia. March 2011
rectly in an educational intervention program when he or she ﬁrst experiences academic difﬁculties. sensory-motor skill. Only the children who do not show signiﬁcant improvement with the ﬁrst-tier group intervention program and the second-tier targeted intense individual intervention program will undergo a full diagnostic educational assessment. Educational decisions about the intensity and duration of interventions are based on the individual student’s response to instruction.100. dyslexia is a clinical diagnosis. and concentrating. Because the hallmark of dyslexia is the presence of a phonologic deﬁcit in the context of relatively intact overall language abilities.FROM THE AMERICAN ACADEMY OF PEDIATRICS
504 of the Rehabilitation Act of 1973.34. this approach will allow earlier and more effective identiﬁcation and treatment than the traditional method in which the child must show persistent poor academic achievement for a few years before referral. and it is not determined solely by medical screening or psychological/IQ testing alone. and remediation. Some schools use Section 504 to support learning-disabled students who need only accommodations. A “wait-to-fail” situation can occur when an ability-achievement discrepancy formula is used to determine if a student qualiﬁes for a formal diagnostic assessment for a learning disability. assessment. clinical psychologist with special training in learning assessments. by observation.100. dyslexia is not diagnosed with testing in the areas of vision. Ideally. Because learning is considered such an activity under the ADA.99 Congress recently passed the ADA Amendments Act of 2008. teachers. The individual student’s progress is closely monitored to assess both the learning rate and level of performance. and the student. educational psychologist. Such evaluation is multifaceted and generally involves interviews with the child and family. Students who do not have 1 of the 13 included disabilities or meet the severity criteria but still require some assistance to be able to participate fully in school may be a candidate for a Section 504 plan. questionnaires and rating scales completed by parents.43. and describing areas of strength and weakness. students served under the IDEA also are covered by this law.97 This act protects the civil rights of students with disabilities and attempts to remove barriers to allow them to participate freely. more people with learning disabilities are now able to satisfy the deﬁnition of disability. Struggling learners are provided with interventions at increasing levels of intensity to accelerate their rate of learning.102. which became effective in 2009.35.44.26 The testing can be conducted by trained school or outside specialists. the diagnosis of dyslexia can be far more speciﬁc.101 Thus. The latest revision of the IDEA. At all ages. or neuropsychologist consists of a battery of tests that will provide information on a child’s overall abilities. medical.101 The majority of these students undergoing educational assessment will likely be identiﬁed as reading disabled and qualify for special education services. or auditory processing. gain access to reasonable accommodations. An evaluation by a developmental/behavioral pediatrician. particularly learning style. The RTI process begins with high-quality instruction and screening of all children in kindergarten to identify any child who exhibits the early signs of potential reading difﬁculties.14 The ﬁrst method is called the response-to-intervention (RTI) method and is designed primarily for the elementary school grades.34 Indicators of phonologic difﬁculties can be detected by a child’s history.14. and/or by speciﬁc tests. Number 3. offers 2 approaches that can be used in the young underachieving child. Furthermore. It expanded the list of major life activities to include reading. the student has suffered the academic and emotional strains of failure for 2 to 3 years before potentially effective instruction can begin. thinking.81 A formal evaluation is needed to discover whether a person has a learning disability. The composition of testing by a school psychologist varies according to state and school district. RTI is a multitiered approach to the early identiﬁcation and support of students with learning and behavior needs.65.
an IEP contract is developed. The IEP contract must be signed by the school professionals and parents before it can be implemented. Neuropsychologists can diagnose learning or behavior disorders caused by altered brain function or development. outline what services will be needed. Under the IDEA. depression.19 Because neuropsychological evaluation is driven by an understanding of the brain systems involved in different academic functions. and treating professionals are interviewed for their presenting concerns. parents may obtain an independent educational evaluation. Such an evaluation traditionally has included critical underlying language skills that are closely linked to dyslexia. evaluation of intellect. revised for the next school year. reading accuracy. language. as well as words in context. health and developmental history. and oppositional features). the diagnosis. phonologic skills. language. Such information helps to identify whether attentional and/or emotional issues might be contributing to or resulting from learning difﬁculties. Parents. The IEP will describe goals and objectives. it can illuminate learning disorders. occupational
e826 FROM THE AMERICAN ACADEMY OF PEDIATRICS
therapy. and set guidelines to measure future educational progress. and socialemotional factors (ie. if appropriate. The determination of the underlying causes of the disorder and comorbid conditions will clarify the types of interventions from which the child is most likely to beneﬁt and will provide a road map on which evidence-based interventions and accommodations are based across home and school environments. attention.ment may include information provided by parents. behavioral rating scales completed by parents. Referring professionals and parents are provided with a detailed written report of test ﬁndings. A student’s ability to read lists of words in isolation. the assessment is called a “neuropsychological” evaluation. Every 3 years. These assessments focus on achievement and the skills needed for academic success. attention and concentration. motor skills. academic achievement. and concentration. the child will undergo comprehensive reevaluation. and referral suggestions. executive skills. and other neuropsychological phenomena to illuminate the neurocognitive underpinnings of speciﬁc learning disabilities as well as their subtypes. including receptive-listening skills. treat-
ment recommendations. executivefunctioning weaknesses. school observations. Children with less
. and comprehension. those results and recommendations must be considered by the IEP team. accommodations. and adaptive levels. executive skills. memory. teachers. teachers. Neuropsychologists with a special competency in the area of pediatrics can perform extensive evaluations that can lead to a comprehensive understanding of the child’s cognitive and emotional processes and provide the gold standard for a learning-disability evaluation. allow predictions to be made about future difﬁculties a child may encounter so that preemptive interventions can be initiated. including phonemic awareness and rapid naming of letters and names.104 To outline the educational goals and services that the student needs to be successful. This information is critical in identifying the speciﬁc deﬁcits relative to the reading weaknesses as well as other comorbid variables that are also involved. socialemotional and behavioral components. adaptive levels. and bring to light comorbid conditions that may not yet have become apparent. If parents obtain an independent educational evaluation on their own and it meets the school’s criteria. Alternatively. if necessary. Addendum IEPs can be held if issues in the initial IEP need to be changed or modiﬁed during the school year. and which type of program would be best. modiﬁcations. The IEP team would still need to determine if the disability and its severity qualify to obtain special education and related services in school. social-emotional and behavioral components.59. speech-language. and school-related records (ie. Neuropsychologists assess intellect. vocabulary. After a comprehensive school evaluation. knowledge of any previous medical conditions. anxiety. The evaluation is necessary for developing a proper treatment plan and should also identify the different instructional methods that are most beneﬁcial at various stages of reading development for each child. a learning disability will be diagnosed formally in some students. School assessments are usually performed to determine if a child qualiﬁes for special education programs or therapies. These variables can include coexisting attention and concentration disorders. review of school records. Section 504 plans and individualized education plans [IEPs]). and. educational. memory. psychiatric. should also be assessed. academic achievement. motor skills. the student. expressivelanguage skills. regulatory capacities. In addition to test data. Eligibility for special education is determined by the IEP team. the services that the school system will provide are listed in the IEP. The IEP is reviewed on an annual basis and. including speciﬁc remedial interventions. After there is agreement by the school professionals and parents. If the focus of the studies is on educational issues as well as on a broader assessment of brain function.55. a “child with a disability” is one who is eligible for special education and related services. perceptual and sensory skills. accommodations. ﬂuency. perceptual and sensory skills. the assessment also involves a review of the relevant medical.
teachers need to be trained on the instructional strategies essential to success for these students. and other appropriate medical specialists may assist in diagnosing and treating any associated health problems if they are
PEDIATRICS Volume 127. vocabulary. Many struggling students will not show severe enough difﬁculties on evaluation to receive a diagnosis of a learning disability and will not be eligible for special education and related services. treatment should be directed at this etiology. including general pediatricians. educational remediation specialists. whereas others need one-onone help so that they can move forward at their own pace. Psychiatrists. 43. phonics. 60. developmental/behavioral pediatricians. 60. or general pediatricians with special expertise may prescribe medications or conduct therapy to improve comorbid psychological disorders. 14.§§ In addition. Phonics is the system of instruction used to teach children
‡‡Refs 1. the focus is on remediation. Physical and occupational therapists do not treat dyslexia but do treat ﬁne motor.34 Remediation. and 63– 65. a Section 504 plan will be written that describes the areas of difﬁculty and lists the accommodations that will be provided in the regular classroom. proprioceptive. and comprehension. 63– 65. 60. family physicians.FROM THE AMERICAN ACADEMY OF PEDIATRICS
severe disabilities who do not qualify for school services may still beneﬁt from remediation and other therapies outside of school at the parents’ expense. ﬂuency training. 30–35. and regular ongoing practice. 63– 65. students with dyslexia often need a great deal of structured practice and immediate. Because many students with learning disabilities receive most of their instruction in general education class. psychologists. 14. Number 3. neurologists. The approach to learning decoding begins with detailed instruction in phonemic awareness and then progresses to sound-symbol association (alphabetic principle). gross motor. Refs 1. Physicians. tutor.107 Highly structured daily intensive individualized instruction by an educational therapist or skilled teacher specially trained in explicitly teaching phonemic awareness and the application of phonics is the foundation for remedial programs.19 A vision specialist for the visually impaired may beneﬁt children with dyslexia who have low vision. The critical elements for effective intervention include individualization. 55. including developmental/ behavioral and neurodevelopmental pediatricians. or therapist who has been specially trained in using a multisensory. Because dyslexia is a language-based disorder. developmental/behavioral pediatricians. corrective feedback to develop automatic word-recognition skills. The instruction must be intensive enough and continue long enough to have a positive effect that will endure. Educational therapists or educators who have been specially trained in learning disabilities develop and implement intervention plans for children with learning disabilities and dyslexia. Clinical psychologists or other mental health providers. 55.63. awareness of rhyme.105 If a student with dyslexia has an outside academic therapist. coordinated collaboration of a multidisciplinary team that may consist of educators.60. In that case.55.34 Students who are easily confused are more likely to be successful when teachers demonstrate and clearly explain what they need to learn.81 The management of dyslexia demands a lifespan perspective. structured language approach.30. and modiﬁcation are used as techniques for overcoming dyslexia and the educational deﬁcits
that it causes.24. ongoing assessment. and 81. which means that children are not expected to infer key skills or knowledge. 43. feedback and guidance. These students still may need targeted reading assistance to be able to participate fully in school and may be a candidate for a Section 504 plan. and word segmentation. the therapist should work closely with the child’s classroom teachers. ophthalmologists. 25. Speech therapists can evaluate and treat underlying oral language difﬁculties often associated with dyslexia or help students learn phonemic awareness. 25. otolaryngologists. 55. 81.22 Many children with dyslexia do well in small group instruction of matched students. It is important for these children to be taught by a sequenced systematic and explicit method that involves several senses (hearing. Treatment for dyslexia consists of using educational tools to enhance the ability to read. and 106.‡‡ Reading instruction should be explicitly taught. The evaluation information may be used to decide what educational accommodations may be needed in a regular education program.33. March 2011
present in these patients.
. mental health professionals. 24. and physicians.34 Remedial interventions should be aimed at the speciﬁc needs of the child and viewed as a dynamic process. special services. touching) at the same time. §§Refs 1. The diagnosis and treatment of a child who has learning disabilities depend on the ongoing. balance. seeing. 32–35. An appropriate treatment plan will focus on strengthening the student’s weaknesses while using the strengths. neurodevelopmental pediatricians. early on. Remedial programs should include speciﬁc instruction in decoding. 24. can provide strategies to help children better cope with social challenges that may be associated with learning disabilities. 14. educational accommodation.58 Most children with dyslexia need help from a teacher.34. and sensory-processing disorders that may coexist in some children with learning disabilities. 30–35.
however. The teaching of children with dyslexia and learning disabilities is a challenge for educators and parents. taped tests.65 To further gain comprehension. lecture notes. making inferences. extra assistance using computers. and state education rules and regulations. syntax.24. Reading aloud will alert parents if a problem exists. spell checkers. lecture tapes. Children
who avoid reading are most in need of practice. and drawing conclusions. By educating themselves in the areas of learning disabilities. Fluency forms the bridge between decoding and comprehension. Ongoing appropriate reading remediation should continue along with these compensatory techniques. requesting an educational evaluation. Schools can implement academic accommodations and modiﬁcations to help students with dyslexia succeed. shortened or modiﬁed assignments. They are also helpful with written examinations and handouts provided by the teacher.14. a line guide. or tutors. and coordinating remediation and other treatment. these activities should be combined with other activities to improve language development. summarization. Sight words need to be memorized. 34. vocabulary instruction. Practicing reading aloud makes feedback possible.24. Daily ﬂuency practice involves repeated guided oral reading of a large amount of text at the child’s independent reading level.25. and 106. A portable scanner can easily scan written material in the classroom and at home and be used with these programs.32–34. visualization. The home is an ideal setting for practice and reinforcement.33–35. Parents should help with practice and reinforcement at home with opportunities to check ﬂuency and comprehension via interactive reading experiences. spelling.34 Comprehension is gained through ﬂuency training. but accuracy does not spontaneously evolve into ﬂuency. help taking notes. Textreading software programs provide an excellent opportunity for students with dyslexia to keep up with reading assignments.81 Many good software programs currently exist and are affordable. Because people with dyslexia have a persistent problem and continue to read slowly throughout their life. parents will increase their effectiveness as the child’s advocate.47. and active reading comprehension. and other professionals. or other testing alternatives. 63. syllable instruction. memorization of sight words. Parental participation in a child’s education is of utmost importance but may be more difﬁcult if the parents are functionally illiterate. They provide relief. and semantics are taught.25. computers for writing. and support. Longitudinal data indicate that systematic phonics instruction results in more favorable outcomes for readers with disabilities than does a context-emphasis (whole-language) approach.24.35 Techniques that enhance active reading comprehension include prediction.
and tests.25. parents should help the child use recommended alternative learning strategies such as books on tape or computers. educational accommodations. available services. The software includes phonetic spelling assistance and intelligent wordprediction features that can address the dysgraphia that often co-occurs with dyslexia. Children with extreme deﬁcits in basic reading skills or those with the double deﬁcit of phonologic and rapid automatic naming difﬁculties are much more difﬁcult to remediate than children with mild or moderate deﬁcits. a separate quiet room for taking tests. Parents should work with educators to ensure that the school provides the proper remediation and accommodations and should continue to monitor their child’s progress and advocate for their child when necessary.34 Children should read aloud to their parents using fun.30
FROM THE AMERICAN ACADEMY OF PEDIATRICS
. The text-reading rate can be adjusted to assist with comprehension. and speeded word-repetition drills should be performed.81 Accommodations allow access to higher-level thinking and reasoning strengths. and spaces can be created to write notes in the text.34.the connection between letters and sounds. morphology.34.63.60. 30. Reading can be bypassed by using tape recorders. with proper remediations. These programs should be a key component of an educational plan. recorded books. pediatrician. and practice is the key to learning to read. especially for older students.34. promote selfesteem. 14. children with dyslexia and learning disabilities can overcome obstacles to improve their reading and writing. text-reading computer programs.55. easyto-read books.¶¶ Later. Reading practice at home should be conducted in a supportive and nurturing environment with adequate opportunity for the child to participate in other activities in which he or she excels.25. Parents should provide ongoing feedback to remediating specialists and should be given the opportunity to ask questions to maximize educational outcomes. extra time for assignments
¶¶Refs 1.55 A child must ﬁrst accurately decode a word before it can be read ﬂuently.64 The brain learns best by practice. As the child gets older. 81.60. it often becomes necessary to adapt the learning environment. 65. and are fun to use. Examples can include preferential seating. Text-reading software is also designed to be used with writing software to allow a student’s writing to be read aloud. Parents need to serve as the child’s advocate by speaking with the child’s teacher. critical thinking. 60.24. clariﬁcation.63.
or articulation problems. An assessment of the child’s activity level. Number 3. such as studies of longitudinal event-related potentials. drug use.108 When a child has suspected learning difﬁculties. attention span. or oppositional deﬁant disorder). Speciﬁc questions on language acquisition and learning should include history of speech delay. may enhance the certainty with which dyslexia can be predicted and promote the possibility of preventive intervention that would allow many more children to succeed at learning to read. General pediatricians should not diagnose learning disabilities but may discuss the possibility with parents. poor instruction. A complete physical examination to evaluate the child’s overall medical and neurologic condition and a psychological. emotional. and alcohol use. A family history of speech and language problems.34 The instruction must be intensive enough and continue long enough to have a positive effect that will endure. the pediatrician or family physician should ﬁrst assess the child for medical problems that could affect the child’s ability to learn and refer him or
PEDIATRICS Volume 127. neurologic problems (such as seizure disorder.98. a combination of behavioral and brain measures. behavioral. physicians. A potential goal in the treatment of dyslexia will be its prevention. and visual difﬁculties. In the future. depression. then the pediatrician should refer the
. or psychiatric problems (anxiety. Children with suspected learning disabilities in whom a vision problem is suspected by the child. Developmental screening as early as 30 to 48 months may identify language or learning concerns.108 If the pediatrician believes that the child has not received a proper assessment at school. or educators should be seen by an ophthalmologist who has experience with the assessment and treatment of children. During well-child visits. primary care physicians should perform hearing and vision screenings according to national standards so that hearing. developmental. Additional medical history should include detection of medical problems (such as chronic or persistent otitis media. and congenital anomalies.108 The physician should take a complete medical history. and visual disorders are identiﬁed as early as possible. and behavioral evaluation should be performed. perhaps together with genetic and familial information. because children 8 years and younger are more likely to show improvement. and timing of the intervention. history of central nervous system infection. emotional. alertness. genetic syndromes.105 Early identiﬁcation and treatment are the keys to helping children with dyslexia. speciﬁc patterns of strengths and weaknesses of the individual child. or poverty for the child or the family should be noted. including determination of maternal drug or alcohol use.109. oc-
ular. March 2011
her for further evaluation if deemed appropriate. lack of reading readiness. learning disabilities. Vision screening with nonletter symbols may be necessary for testing children with dyslexia or other learning disabilities. Brain measures. and refractive errors. and the appropriateness. amount. asthma.108 A child should receive medical and psychological interventions as appropriate for diagnosed conditions. thyroid problems. the recommended routine pediatric vision screenings are unlikely to disclose near-vision problems such as convergence insufﬁciency. difﬁculties in learning letters or phonics. Pediatricians and primary care physicians play an extremely important function in acting as a medical home by helping parents decide whether further evaluations are needed and in coordinating care for the child after a diagnosis has been made.110 Children who do not pass vision screening should be referred to an ophthalmologist who has experience with the care of children. neonatal/birth problems. convergence and/or focusing deﬁciencies. cooperation. or lead poisoning). Primary sensory impairments should be ruled out by hearing and vision screenings. A social history should be taken.109 Periodic eye and vision screenings can identify most children who have reduced visual acuity or other visual disorders.FROM THE AMERICAN ACADEMY OF PEDIATRICS
The prognosis depends on the severity of the disability.53
ROLE OF THE PEDIATRICIAN AND PRIMARY CARE PHYSICIAN
Pediatricians and primary care physicians can serve a number of important functions for children with dyslexia and their family members. amblyopia.110–113 Treatable ocular conditions can include strabismus.98. and ability to communicate should be noted. intensity. overall academic achievement. or functional illiteracy should also be noted. cultural differences. obsessive compulsive disorder. accommodative insufﬁciency. or autism spectrum disorder. and signiﬁcant hyperopia. head trauma. physicians should inquire about the child’s educational progress and be vigilant in looking for early signs of evolving learning disabilities. For all children. speech difﬁculties.110 In addition. or any chronic disease that may have caused school absences). ADHD. because some of these children may also have a treatable visual problem that accompanies or contributes to their primary reading or learning dysfunction. Missing these problems could cause longterm consequences from assigning these patients to incorrect treatment categories. have shown impressive relations between brain responses at infancy and later language and reading success or failure. parents.
111 When parents inquire about a new technique or treatment concept. a disease or developmental problem that affects the brain. Despite the condition. Early optometric studies that have indicated increased hyperopia in children with reading difﬁculties are of limited signiﬁcance. have difﬁculties with reading the board at school but no difﬁculty with near vision. Referral to an educational psychologist for psychoeducational assessment for the purpose of identifying special needs should be considered if the primary issue is the child’s educational performance or learning problems. thus.”111 Parents need to be informed that dyslexia is
e830 FROM THE AMERICAN ACADEMY OF PEDIATRICS
a complex disorder and that there are currently no quick cures. Physicians who have a strong role in assisting school districts should recommend only evidence-based treatments and accommodations. and the ADA. emotional.108 Pediatricians and primary care physicians should provide information and support to parents on learning disabilities and their treatment and should dispel the myths surrounding these disorders. For patients with complex or long-standing educational problems that have been difﬁcult to remediate. Section 504 of the Rehabilitation Act. referral to a neuropsychologist. children with uncorrected high hyperopia may be uninterested in books and near tasks and secondarily experience difﬁculty starting to read. clinical psychologist with special training in learning assessments. Good visual clarity and resolution are necessary to discern small print.114 Pediatricians and primary care physicians should be familiar with the IDEA. behavior. In 1 study. developmental/behavioral pediatrician.00 diopters (D) of hyperopia in the ﬁrst 5 years of life and then gradually decreases into adolescence.111 Amblyopia causes reduced visual acuity and susceptibility to the crowding phenomenon. including hyperopia or a need for glasses. because they are likely to waste time and resources. or moderate astigmatism have any greater difﬁculty in learning to read than do other children. socialization. They should also discourage school districts and parents from pursuing treatments that are not evidence based. Pediatricians and primary care physicians should compile and provide a resource list of local specialists from whom the child can obtain proper help and from whom the family members can learn to become advocates for the child.98. a difﬁculty with distinguishing letters in close proximity to one another. Children with uncorrected myopia will have reduced distance visual acuity and. attention.
are normal in young children and are usually of no pathologic signiﬁcance. neurodevelopmental pediatrician.) Nonmyopic signiﬁcant refractive errors are present in 10% of children younger than 12 years. The average refraction of white children in the United States is nearly 2. microstrabismic amblyopia was associated with slower reading rates but not with dyslexia.116 Before diagnosis and treatment.26 This discussion should include providing the parents with information regarding the lack of proven efﬁcacy of vision therapy and other “alternative treatments.96 Information for pediatricians on this legislation and its associated rights and procedures is available from the American Academy of Pediatrics.108 Physicians can refer parents of children with learning disabilities to their state’s parent training and information center. There is no evidence that children with moderate myopia. The American Academy of Pediatrics has information for families on what parents need to know about learning disabilities. These parentdirected centers provide information and technical assistance to parents and professionals about family and student rights and responsibilities in special education. children with myopia have been found to be average to above-average students. or emotional control. physicians should be ready to discuss the treatment and the current knowledge about its efﬁcacy.115 There is no correlation between reading performance and any speciﬁc type of refractive error. bilateral cataracts. ﬁxation is usually performed with the fellow. developmental/behavioral pediatrician. neurodevelopmental pediatrician. and retinal or optic nerve prob-
THE EYES AND VISION
Visual Acuity and Refraction Books for beginning readers usually have very large print of approximately 20/200 to 20/100 size. In children with amblyopia.child for an outside independent educational evaluation by an educational psychologist. because these acts deﬁne the rights of students with dyslexia and other speciﬁc learning disabilities. or neurologist with appropriate expertise. Small amounts of hyperopia
. because the studies did not have control groups and were generally unreliable because they were performed without cycloplegia. A child should be referred to a neuropsychologist for problems such as learning.95–97 The IDEA allows parents to request a formal educational evaluation by the school district to determine eligibility for special education. nonamblyopic eye/visual system. and behavioral functioning. or neurologist with appropriate expertise should be considered for a more indepth evaluation of brain function to asses overall cognitive. moderate hyperopia.117 Nystagmus. or a brain injury from an accident or birth trauma. neuropsychologist. but they do not have an increased likelihood of true dyslexia.115 (A diopter is the unit of measurement of the refractive power of lenses equal to the reciprocal of the focal length measured in meters. but only in the amblyopic eye/visual system.
The duration of a ﬁxation varies with the difﬁculty of the text being read. as in English. not because of a “tracking abnormality. and 134–136. Fifty percent. 111. the difﬁculty of the text. young children can read comfortably at 6 in for a prolonged time.137 Problems such as nystagmus interfere with foveal ﬁxation time. Early readers use more backward saccades. but there is no evidence to suggest that saccadic training results in better reading. Reading uses both forward (rightward in English) saccades (85% of saccades) and backward or regression (leftward in English) saccades (15% of saccades). Thus. and either esophoria or exophoria.120 Backward saccades are used for veriﬁcation and comprehension. has not been shown to be a predictor of reading disability. Duane syndrome.136 Chil##Refs 14. nonspeciﬁc viral illness. 116.125 Accommodation Accommodation is the ability to focus accurately at near and is necessary for reading at near. and the length of the word before the saccade. increase with the difﬁculty of the text. rather. Early anecdotal publications in the optometric literature in the 1950s reported a possible oculomotor deﬁcit that disrupted the normal saccadic reading pattern. and abnormal eye movements such as those with congenital motor nystagmus have shown the ability to learn to read ﬂuently. More letters are processed to the right of ﬁxation if the eye is scanning from left to right.58 Saccades and Fixations The eye movements used in reading are not similar to a typewriter typing. The saccadic patterns seen in readers with dyslexia appear not as a cause but as a result of their reading disability. increased duration of ﬁxations. are responsible for slow reading. children who are blind are able to learn to read using Braille. the incidence of accommodative insufﬁciency is low. Number 3.138 There is no proof that
. many studies subsequently have demonstrated that ocular coordination and motility are normal in children with dyslexia. Visual perception is suppressed during saccades. or 7 D. Furthermore. many medications. thus. symptoms can include discomfort or blurry or moving vision.121–129 No difference was found between adults with dyslexia and controls on measures of saccadic accuracy and saccadic latency.FROM THE AMERICAN ACADEMY OF PEDIATRICS
lems can interfere with visual acuity. Decreased accommodation has been associated with uncorrected high hyperopia. and increased backward saccades. In contrast. Children with severe visual impairment are able to learn to read with assistance from spectacle correction for refractive errors and low-vision appliances. 118–128. high-velocity.138. March 2011
over to the next ﬁxation point. dyslexia is not the result of oculomotor deﬁcits but.136 Reading uses saccades that are shortduration. In the pediatric population.119 Scanning a line of text in English involves a sequence of rightward and leftward saccades. which corresponds with a near point of accommodation of 2 to 3 in.111. Experienced readers use longer saccades of approximately 2 degrees or 8 letters of average-sized print text.## Decoding and comprehension difﬁculties.111. rather than a primary abnormality of the oculomotor control systems.125 Simulated saccadic “abnormalities” can be created by giving normal readers overly complex material or material in a new language. local ocular trauma. the result of more central processing problems.118 When ﬁxated. ocular disease does not affect the ability of children to learn to read.139 If it is present.122 Results of 3 studies by Rayner et al131–133 were consistent with visual/linguisticcontrol models of eye-movement control and inconsistent with visual/ oculomotor-control models.118 Fixations may last 45 to 450 milliseconds and average 180 milliseconds.118. In general. is available for sustained near activity. Findings of accommodative insufﬁciency may include decreased visual acuity at near.
dren with dyslexia often lose their place while reading because they struggle to decode a letter or word combination and/or lack attention or comprehension. the eye rests on a content word and takes in a span of approximately 7 to 9 letters to the right of ﬁxation and 3 to 4 letters to the left before it jumps
PEDIATRICS Volume 127. The saccade length depends on the ability to recognize letters. Readers with dyslexia have shown normal sequential saccadic tracking in tasks other than reading and oculomotor functioning. which constitute 90% of our reading time. yet affected children have not shown an increased likelihood of dyslexia. a remote monocular near point. Moebius syndrome. accommodative lag.137 Dyslexia is no more frequent in these children with signiﬁcant eyemovement disorders than in the general population. Smooth pursuit or tracking eye movements are not used in reading. small jumping eye movements.” Children with saccadic disorders. The average amplitude of accommodation in children younger than 10 years is 14 D.130 Readers with dyslexia have shown saccadic eye movements and ﬁxations similar to those of the beginning reader and have shown normal saccadic eye movements when content is corrected for ability. Vision impairment. and are also used to jump to the next line.122 Improving reading has been shown to change saccadic patterns. and the opposite would be true for reading a language than is scanned from right to left. Visual information is perceived during foveal ﬁxations. Accommodative amplitudes are maximal in childhood and decrease naturally with age. and functional problems. 112. in itself.
illness. Larsen et al150 found no differences in visual perception between normal and learningdisabled children. visual skills do not reliably distinguish children who differ in reading ability. because only a few children who are poor readers actually suffer from perceptual malfunctions.29 The vergence system works to maintain fusion so that the eyes remain aligned on a visual target. teenagers. 135. These ﬁndings should be accompanied by a low convergence fusional amplitude.3% to 0.to 12-year-olds in which ﬁndings alone were used classiﬁed 51% of the children with possible convergence insufﬁciency. In short. The diagnosis of convergence insufﬁciency is relevant only if there are multiple ﬁndings accompanied by signiﬁcant symptoms. Although vision is necessary for reading. Patients typically present as teenagers or young adults with gradually increasing complaints of discomfort. some studies report the prevalence as being as low as 0.146 A study of 735 children found no signiﬁcant difference in school achievement for children who showed convergence insufﬁciency and those who did not. 134.18 Convergence amplitudes have not been correlated with reading comprehension.116.111 Difﬁculties in accommodation do not interfere with decoding but can interfere with the child’s ability to concentrate on print for a prolonged period of time.14.there is a difference in accommodative ability between normal and abnormal readers. These latter ﬁndings alone do not constitute the diagnoses of convergence insufﬁciency.
. and adults may become symptomatic because of large amounts of demanding near work and reading while fatigued. that should be considered a normal variant. known as tropias (eg. The prevalence of convergence insufﬁciency has been reported to be in ape832 FROM THE AMERICAN ACADEMY OF PEDIATRICS
proximately 3% to 5% of the population. 9–12. 119–128.15. and anxiety are known to aggravate the problem. also has not been associated with dyslexia. because it leads to classifying many normal children as abnormal. because they may be present with good convergence. The presence of 500 seconds of arc of stereopsis is required. and 149–151.142. orthophoria. 15. 137.29 Binocular Vision True orthophoria—perfectly straight eyes— occurs rarely. A study of more than 3000 unselected students revealed a near phoria in most children.17. many theories have implicated the visual system in the causation of dyslexia. Older children. Convergence is the inward turning of the eyes and is used for near reading. The diagnosis of convergence insufﬁciency is based on a remote near point of convergence or difﬁculty in sustaining convergence combined with asthenopic symptoms (sensations of visual or ocular discomfort) at near.147 Convergence insufﬁciency can interfere with a child’s ability to concentrate on print for a prolonged period of time but does not interfere with decoding. However. Historically. Several studies have investigated the connection between reading ability and the binocular and accommodative status of unselected children.141 Of these ﬁndings. Visual deﬁcits of the types from the early literature were found to be no more prevalent in poor readers than they
***Refs 2.14. because of the differences in diagnostic criteria. Robinson and Schwartz149 found no correlation between visual-perceptual abilities and reading ability. Vellutino et al14 found no statistically signiﬁcant differences in the studies between poor and normal readers on measures evaluating visual recognition and visual recall of letters and words. The demise of these theories began in the 1980s with a series of related studies that systematically evaluated deﬁcits in visual processes such as visualization. 14. The disorder is much less common in children younger than 10 years.148 Visual Processing Processing of visual input is a higher cortical function. blurred vision. 116. and/or a large exophoria or intermittent exotropia at near with a smaller exophoria. Various authors deﬁne convergence insufﬁciency differently. a latent deviation usually esophoria or exophoria. Larsen and Hammill151 found no predictive relationship between standardized tests of visual perception and reading ability in their review of 60 studies.*** In their review in 2004. most people demonstrate a small asymptomatic phoria.143 whereas a retrospective study of 8.140. The incidence of ADHD was reported in 1 study to be increased in children with convergence insufﬁciency. No causal relationship was found between normal variants and reading/ writing difﬁculties. visual sequencing. the most important are the ability to obtain and maintain convergence.111 Decoding and interpretation of retinal images occur in the brain after visual signals are transmitted from the eyes. it is the brain that must perform the complex function of interpreting the incoming visual images. esotropia
and exotropia). and visual memory as basic causes of reading difﬁculties. or esophoria at the distance. Lack of sleep. eyestrain.144 This classiﬁcation system is obviously not valid. or diplopia during extended periods of studying.113 Manifest strabismus.15 Visual theories of reading disability have become less and less popular. headache. Morrison et al152 found no perceptual deﬁcits in children with reading disabilities.8%.145 but additional analysis has revealed that the reported incidence was actually average when compared with large studies in which the prevalence of ADHD was evaluated.
and eye-hand coordination. amblyopia. treatment of these disorders can make reading more comfortable and may allow reading for longer periods of time but does not directly improve decoding or comprehension. The strength should be based on the child’s weight.158 In school-aged children without strabismus or amblyopia. eye drops.157. if visual deficits were a major cause of reading disabilities.154 The medical history should include detection of any medical condition that could interfere with the child’s ability to learn or a chronic medical illness that could cause school absences or difﬁculties concentrating or learning.00 D to 4. Playing video games requires concentration. astigmatism at 1. Finally. It is important for the ophthalmologist to recognize that healthy children often have visual complaints from normal visual phenomena such as physiologic diplopia and relaxation of accommodation.159 Myopia and astigmatism are fully corrected. Thus. blepharitis. Convergence and accommodation are also required for handheld games. visual perception.15.110. and refractive errors may require glasses. Cycloplegia with either 1% or 2% cyclopentolate is necessary for accurate refraction in young children. signiﬁcant refractive errors. eye movements. Signiﬁcant refractive errors can make reading more difﬁcult. such as asthenopia and reduced visual acuity or lack of symptoms. whereas children with refractive error (78%).29 Thus. because some children may also have a treatable visual problem along with their primary reading or learning dysfunction.50 D to 2. Many children with reading disabilities enjoy playing video games. or eye muscle surgery in accordance with standard principles of treatment.
PEDIATRICS Volume 127. can interfere with the physical act of reading but not with decoding and word recognition. Vision testing with nonletter symbols may be necessary and may be especially important for testing children with dyslexia or other learning disabilities. iris coloration.110–113. Convergence insufﬁciency and poor accommodation. The ocular history should include any eye or vision complaints that may make it difﬁcult for the child to concentrate on reading for extended periods of time. visual processing.153 Other than the need for long-term optical correction. prisms.00 D. both of which are uncommon in children.155 Also. depending on the clinical situation. Strabismus.15. however. a dilated retinal evaluation should be performed. children with suspected or diagnosed learning disabilities should undergo a comprehensive pediatric medical eye examination by an ophthalmologist who has experience with the assessment and treatment of children. most children (82%) who complain of eyestrain and headaches have a normal eye examination. including cycloplegic refraction.00 D or greater. improvement in school performance should be observed once the problem is corrected. In eyes with heavily pigmented irides. Children with developmental delay or Down syndrome often hypoaccommodate and may beneﬁt from spectacle correction at lower thresholds. whereas high hyperopia is often undercorrected by up to 50% but no more than 3. or strabismus (58%) are free of eyestrain. these problems generally do not require extended treatment programs.50 D or greater. March 2011
ROLE OF THE OPHTHALMOLOGIST
Because routine pediatric vision screening is not designed to detect problems with near vision.00 D to 1.112.00 D or greater. not a cause. hyperopia at 4. amblyopia. including handheld games.75 D or greater.111. which makes these complaints a poor marker of eye conditions in young children. The eye examination should place special importance on the detection of undiagnosed vision impairment by assessing visual acuity at the distance and near. anisometropic hyperopia at 1. correction of myopia should be considered approximately at 0. vision problems can interfere with the process of reading. or strabismus.110.FROM THE AMERICAN ACADEMY OF PEDIATRICS
were in normal readers.122 Word reversals and skipping words and lines were attributable to linguistic deﬁciencies and not visual or perceptual disorders. convergence training. vision problems are not the cause of dyslexia. adjunctive agents such as tropicamide and/or phenylephrine hydrochloride may be necessary to achieve maximal cycloplegia and pupil-
lary dilation.156 The ophthalmologist should perform a complete dilated eye examination.14.14. amblyopia (68%).50 D or greater.110 These guidelines should be adjusted on the basis of the patient’s visual needs and symptoms.59 In summary. these children would reject this vision-intensive play activity. Retinal or optic nerve problems can lead to strabise833
. eye patching.50 D or greater.159 A careful external ocular examination should be performed to determine if the child has problems such as dry eyes. and dilation history. anisometropic myopia at 2.29 If reading impairment is attributable solely to a visual problem. Number 3. and anisometropic astigmatism at 1. of reading disorders. for prolonged periods. or ocular allergies that could cause eye irritation that can secondarily interfere with his or her ability to concentrate and learn. few signiﬁcant differences were found on measures of visual processing ability when the inﬂuence of verbal coding was controlled. In many studies that compared poor and normal readers.14 Difﬁculties in maintaining proper directionality have been demonstrated to be a symptom.
blurry vision. The accommodative amplitude can be assessed by using increasing minus lenses while the child reads monocularly. stereopsis. amblyopia. The American Academy of Ophthalmology and American Academy of Pediatrics have patient-education brochures for families on learning disabilities. orthoptic therapy has been adapted into simple visual tasks that can be taught in the ofﬁce and conducted by the patient at home. dynamic retinoscopy can provide a rapid assessment of accommodative function and may be helpful in evaluating a child with high hyperopia. Clark stick. for other patients. and headache. children are reevaluated in the ofﬁce on a monthly basis. the ophthalmologist should identify and treat any signiﬁcant visual defect according to standard principles of treatment. Symptomatic accommodative insufﬁciency can cause blurry vision and discomfort. Distance. bifocals are rarely needed by children. it can be treated with near-point exercises. The accommodative facility can be assessed by alternately applying 2. Lang.168
SCIENTIFIC RESEARCH AND DISSEMINATION TO THE PUBLIC
Science advances by a process of modiﬁcation. or other appropriate evaluation or services.00 and 2.110.161. that this condition is rare. Home computerbased convergence exercises are a newer method of treatment. reading glasses with base-in prism or occlusion during reading can be used to treat the symptoms of diplopia but not the underlying convergence insufﬁciency. the ophthalmologist should dispel myths surrounding these disorders and discuss the lack of proven efﬁcacy of vision therapy and other alternative treatments with the parents. Symptomatic accommodative insufﬁciency with a near point of accommodation well outside established norms can be treated with reading glasses or bifocals. Over the years.161 Intensive in-ofﬁce vision therapy is effective but not required. photophobia. hence. diplopia. accommodation. numbers.158. Ocular alignment is assessed by using the corneal light reﬂection. If an ocular misalignment is detected. Symptomatic convergence insufﬁciency can cause discomfort. eyestrain. or Costenbader accommodometer. A continuous process of research and testing needs to take place to show that a treatment has demonstrable effect and beneﬁts and to compare effectiveness between treat-
. whereas fusion can be tested with the Worth 4-dot test or Bagolini lenses. or possible accommodative insufﬁciency. psychological. the binocular red-reﬂex (Bruckner) test. binocular function.162 Gen-
erally. Ocular versions and ductions should be evaluated. and convergence. or pictures.160 Before cycloplegia. it must be emphasized.00 lenses while the child reads monocularly.mus. which can contribute to difﬁe834 FROM THE AMERICAN ACADEMY OF PEDIATRICS
culties in concentrating on print for prolonged periods of time. multiple measurements of the ocular deviation using prisms in 1 or more ﬁelds of gaze at distance and/or at near is necessary. Near-point convergence exercises generally consists of push-up exercises using an accommodative target of letters.153. To improve reading comfort. cover testing is most important. reduced visual acuity. Treatment of accommodation difﬁculties can make reading more comfortable but does not improve decoding or comprehension. push-up exercises with additional base-out prisms. should compile and provide a resource list of local specialists to assist in obtaining proper help for the child. recession from a target. the child needs no further vision treatment. when necessary.161.and near-convergence amplitudes can be measured by using a base-out horizontal prism bar or rotary prism while the child is reading.153. however.29 In summary. Emphasis should be placed on the evaluation of ocular alignment. stereogram convergence exercises. and maintaining convergence for 30 to 40 seconds.140.166 If no ocular or visual disorder is found. or computer-based convergence exercises.163–165 Alternatively. and. These tests can be performed at both near and distance when necessary. jump-to-nearconvergence exercises.167 In addition. but this approach does not directly improve decoding or comprehension.167 The ophthalmologist. accommodative lag. The monocular near point of accommodation can be measured by conventional push-up technique using a ruler. and many children enjoy using the computer program. or stereo ﬂy test. and alternate-cover tests in primary gaze with accommodative targets at distance and near when feasible.114. Stereoacuity can be evaluated with the random dot E.29 The near point of convergence should be tested by using an accommodative target and measured with a ruler. cover/uncover. Near visual acuity should be assessed in the evaluation of accommodation. educational. prism convergence exercises. Symptomatic accommodative infacility may cause difﬁculty in shifting from far to near and near to far. Symptomatic convergence insufﬁciency is a treatable condition. The ophthalmologist should not diagnose learning disabilities but should provide information on learning disabilities and reinforce the need for additional medical.140. rarely.140 The treatment of convergence insufﬁciency can help reading become more comfortable and may allow reading for longer periods of time. which can contribute to limited ﬂuency by interfering with the child’s ability to concentrate on print for a prolonged period of time.
a physician cannot read the study abstract alone and be conﬁdent of the conclusion. The practice of EBM integrates individual clinical expertise with the best available external clinical evidence from systematic research. lastly. randomization method. Good research is rigorous and objective and requires peer review. progress in medicine has been based on controlled studies. Number 3. and.173 Poorly conducted research may produce false-positive or false-negative results. and attrition. methodologic. the results or the conclusions may be skewed or biased to seem to be consistent with hypotheses proposed. some pattern will likely be found. An advanced hypothesis and appropriate statistical methodologies to control the probability of false-positive ﬁndings are essential for demonstrating credible scientiﬁc ﬁndings. new statistically signiﬁcant outcomes are introduced for publication. unrelated researchers. Selection bias includes self-selection. a study of efﬁcacy compares a treatment with a placebo or another treatment by using a double-masked controlled trial and well-deﬁned protocol.172 The Hawthorne effect may occur and bias the research when the experimental subjects change their behavior as a result of being observed. The public is largely uninformed about the hallmarks of good research.
posthoc subgroup analysis is performed. A positive ascertainment bias leads us to remember only positive results and positive studies. Reports should describe enrollment procedures. Conclusions may be misleading or artiﬁcially inﬂated when data-derived. Serious scientiﬁc. when a lot of data are collected without a speciﬁc hypothesis in advance. Over the last 50 years. Age-matched control groups are important in learning-disability studies. not in response to any particular experimental manipulation. All associated conditions or treatments should be controlled. nonsigniﬁcant primary outcomes are omitted from reports. or statistically signiﬁcant secondary outcomes are upgraded to primary end points. There should be documented objectivity associated with research. Large-scale stude835
. eligibility criteria. To use EBM.FROM THE AMERICAN ACADEMY OF PEDIATRICS
ments. EBM is the use of the most reliable current evidence to make treatment decisions. Thus. The ﬁnding of an association is not a ﬁnding of cause and effect.” Many types of statistical bias or other problems can be present in published
PEDIATRICS Volume 127.171. False-positive results are more likely in clinical trials that examine highly improbable hypotheses compared with hypotheses with a stronger basis in science. and statistical ﬂaws noted in some study reports that invalidated their conclusions are discussed in “Controversial Theories and Therapies. Research ﬁndings should be tested and scrutinized from many angles by multiple. Manipulation of the data by rejection of “bad data” or “outliers” leads to biased data. control conditions. subject prescreening. and statistical analysis have been critically evaluated. when possible. there should be replication. In poor research.170 The physician must not take the conclusion seriously until the appropriateness of the study design. Evidence-based medicine (EBM) categorizes different types of clinical evidence and ranks them according to the strength of their freedom from various biases. A study with more preliminary supporting evidence is more plausible than one with weak or no previous supporting evidence. Standardized outcomes and appropriate statistical analyses should be used. Properly performed scientiﬁc studies offer the possibility of validity. The multiplicity problem may occur when the more often a hypothesis is tested.112 Good baseline similarities of the population and the medical condition is necessary to compare like with like. methodology. methods for diagnosis. Studies that do not control for the placebo effect may produce false-positive results. case reports. clinical characteristics of the patients. Alternative medicine makes most of its claims by unsubstantiated testimonials. the physician should investigate the medical literature efﬁciently. placebocontrolled. The “evidence pyramid” ranks testimonials. Ideally. Studies with controls and “no-treatment groups” are necessary to evaluate the size of the placebo effect. The placebo effect may be a large portion of the positive responders. Critical appraisal is a systematic process used to identify the strengths and weaknesses of a research article to assess the usefulness and validity of its ﬁndings. anecdotes. the data are not useful. If the study is not valid. March 2011
scientiﬁc study reports. Similarly. The issue of validity speaks to the “truthfulness” of the information. and case studies as poor sources of scientiﬁc information. Conﬁrmation bias occurs when experiments are designed to seek conﬁrmatory evidence instead of trying to disprove the hypothesis. double-blinded studies. and length of treatment. Positive studies are more likely to be published than are negative studies because of publication bias. evaluate the results. the more likely a positive result will be obtained. deﬁnition of treatment. read the methodology section to evaluate the quality of the evidence to determine the validity of the study. Preliminary positive results in smaller studies often are not repeatable in larger randomized. and. The comparison groups must be the same except for the factor that is being studied. Nonrandom sampling leads to difﬁculties generalizing the data.169 EBM is open to new evidence and revised conclusions.
175 The result is that a large share of the science seen by the public is ﬂawed because of minimal or distorted scientiﬁc facts.179 has written many articles on controversial therapies including vision therapy. which circumvents the normal process of scientiﬁc review and debate. The work is often performed at no charge.183.183 The magnocellular component of the visual system is important for timing visual events and controlling eye movements when reading. the use of tinted lenses or ﬁlters and vision therapy for learning disabilities does not follow these standards. placebo-controlled trials that involve good baseline similarities of patient population and medical condition with an adequate follow-up time and low study participant attrition rate.176 In 1984.184 It is postulated that the magnocellular system suppresses the parvocellular system at the time of each saccade. He stated that a treatment approach can be considered suspect if the approach is proposed to the public before any research results are available or preliminary research has not been replicated.ies provide more reliable conclusions by reducing the margin of error. the public must learn to carefully evaluate the information received in the face of aggressive promotion. randomized. According to Helveston. Some scientists report their claims directly to the media. especially with regard to prematurely disseminated therapies. Silver178. Helveston177 stated that it has become traditional in medicine for new and unproven treatments to be evaluated under a protocol by qualiﬁed investigators on patients who give informed consent after the risks and beneﬁts have been explained. The strongest evidence for therapeutic interventions is provided by carefully designed large-scale. The media now play a major role in providing information or misinformation on new scientiﬁc developments to the public. He noted that parents often abandon common sense in their quest to help their struggling children and become easy prey for therapists who promise a cure. The visual system is composed of 2 parallel systems: the magnocellular (largecelled) (transient) system and the parvocellular (small-celled) (sustained) system. yet the approach is still advertised commercially.170 From a scientiﬁc perspective.
CONTROVERSIAL THEORIES AND THERAPIES
Magnocellular Deﬁcit Theory There is continuing interest in lowlevel impairments of the visual system as an etiologic factor in dyslexia. He stated that the chronic nature of learning disabilities offers the ideal environment for fraud and quackery. or there is clear research evidence showing that the approach does not work. and the parvocellular system is sensitive to lowfrequency and ﬁne spatial details. It often takes years to convince the research community that a theory has merit.181. dramatic presentations. The research community is willing to embrace a theory only when there is substantial convergent evidence from multiple sources. Worrall181 recommended that the public be suspicious of any therapy that claims to treat a large number of illnesses. the approach is used in an isolated way when a multimodal assessment and treatment approach is needed. Levine warned that in such cases. and fervent anecdotal reports of cure may convince school personnel and parents that visual training is the answer. Levine128 stated that pediatricians (and ophthalmologists) must
e836 FROM THE AMERICAN ACADEMY OF PEDIATRICS
serve as scientiﬁc consumer advocates and help parents. and results are reported for peer review. This public information can inﬂuence the behavior of clinicians and patients. double-blinded. it is important to also remain openminded. This suppression terminates the activity in the parvocellular system to prevent ac-
. the treatment approach is
being commercially promoted before the research shows any support for the proposed treatment. Only when the aforementioned criteria are met and it is shown that treatment is effective is treatment customarily offered on an unrestricted basis.183 The magnocellular system responds to high temporal frequency and object movement. Aggressive marketing. teachers. and the community at large to evaluate claims and insist on hard evidence regarding diagnostic and therapeutic modalities. loosely reviewed journal articles. Scientists hesitate to accept research results unless they can demonstrate a statistical probability of more than 95% that the observations are not attributable to chance. “healthy skepticism” should be adopted by the research community174 and the public. They may report claims by a tiny minority and place them on equal footing with the majority opinion or report claims before any research.182 Thus. Public health messages are inadequate or distorted when journalists ignore complexities or fail to provide context. Although it is prudent to be skeptical. Media hype of the overstated ﬁndings of poorly designed research may change behavior and harm public welfare. Kennedy et al180 stated that unvalidated treatments often claim to be effective against a range of disorders with different symptoms and etiologies. but it frequently takes no time at all to convince the public. the proposed approach goes beyond what research data support. the pediatrician may be bypassed and considerable family and community resources may be diverted toward unsubstantiated interventions.
word-decoding rate. Reading errors have been attributed to instabilities in binocular vision that result from destabilization of binocular eye position. Their conclusion was that it is possible that a defect in the magnocellular pathway creates a timing disorder that precludes rapid and smooth integration of detailed visual information necessary for efﬁcient reading. blue.183–187 The studies supporting this theory are outnumbered by studies
that have found no loss of contrastsensitivity and other studies that have found contrast-sensitivity reductions or other ﬁndings inconsistent with a magnocellular deﬁcit. which challenges the view that dyslexia is the result of a magnocellular deﬁcit. March 2011
rapid changes of the stimulus. and abnormal binocular control. A letter to the editor from Victor190 interpreted the ﬁndings of Lehmkuhle et al as showing that the equalization of the responses of normal readers and readingdisabled subjects with the addition of the ﬂickering background reﬂects not only an increase in response latency in subjects with no reading disability but also a statistically insigniﬁcant shortening of response latency in readingdisabled subjects. May et al189 found that the latency periods were shortened under low spatial frequency conditions. Amitay et al hypothesized that the magnocellular pathway deﬁcit is part of a more generalized deﬁcit in fast temporal processing of visual. This visual trace could be responsible for complaints of visual distortion and moving print in some people with dyslexia. This ﬁnding was not reproduced in a larger study by Victor et al.204 and others refute it. Hutzler et al129 suggested that pathologic abnormality in the magnocellular system may coexist with dyslexia but that it is not causal. Many researchers have concluded that magnocellular system deﬁcits and associated visual trace persistence are not signiﬁcant causes of speciﬁc reading disability. which would result in a failure to keep separate neural activity elicited during different ﬁxations. Stein and Walsh184. Skoyles and Skottun202 calculated that more people without dyslexia have magnocellular deﬁcits than those with dyslexia. eye-movement recordings have shown that poor readers and age-matched normal readers have comparable stabilities in binocular ﬁxation. The magnocellular deﬁcit theory of dyslexia proposes that without this suppression. tinted ﬁlters. visual. In another article. blue transparencies signiﬁcantly improved reading comprehension in all groups but reduced the reading rate.187 suggested that this deﬁcit in the inhibitory function of the magnocellular system produces a visual trace of abnormal longevity that creates masking effects along with visual acuity problems when reading connected text. the parvocellular activity from different ﬁxations would be confused. Most of the evidence supporting the magnocellular theory comes from contrast-sensitivity and functional MRI studies on visual movement processing. However. the evidence in support of the magnocellular theory is equivocal at best. Reading accuracy. In 1991. Stein and Walsh187 concluded that people with dyslexia may be unable to process fast incoming sensory information adequately in the phonological. they consistently showed impaired performance in auditory and nonmagnocellular visual tasks.183–187. It was concluded that the temporal deﬁcits were attributable to a defective magnocellular visual pathway. Breitmeyer183 proposed that reading disability is an expression of the disruptive effects of a temporal processing deﬁcit in the magnocellular system.188–201. and perceptual information.14. Number 3. visuospatial attention. Speciﬁc reading disability in a small subset of patients with dyslexia has been attributed to a deﬁcit in the magnocellular visual system.188 who concluded that it was unlikely that a simple loss of magnocellular function readily manifest in the visual evoked potential is causally and speciﬁcally related to dyslexia. Also in opposition to Livingstone et al. Victor further stated that this ﬁnding deﬁes a simple interpretation in terms of a loss of the magnocellular input.188–190. However. Amitay et al191 found that although some (6 of 30) subject with dyslexia showed impaired magnocellular function. Selective disruption of the magnocellular pathway via the posterior parietal cortex in certain people with dyslexia could lead to deﬁciencies in visual processing. Livingstone et al186 found that disabled readers had abnormally long visual evoked-potential latencies in conditions of low contrast or with
PEDIATRICS Volume 127. and no overlay. The authors noted that these ﬁnde837
.188–201 Thus. Lehmkuhle et al185 noted the lack of change in the latency of the visual evoked potential in reading-disabled children compared with the increased latency noted in children without a reading disability by using low spatial frequency target and high-frequency ﬂicker ﬁelds. auditory.205 Iovino et al204 evaluated 60 children with reading disability and comorbid conditions involving mathematics and ADHD in 1998.192–203 Some study results involving tinted lenses. In 1993.183–187 In 1983. Colored overlays did not differentially affect the reading performance of subjects with and without reading disabilities. and motor systems. or occlusion seem to support the magnocellular theory. and reading comprehension were assessed by using red.FROM THE AMERICAN ACADEMY OF PEDIATRICS
tivity elicited during a ﬁxation from lingering into that from the next ﬁxation. because this pathway preferentially responds at higher temporal rates and lower contrasts.
Although the basis of SSS is unknown and the syndrome may not exist. reactive attachment disorders. Hoyt209 and others have maintained that SSS is not a recognized medical syndrome and consists merely of a group of vague and nonspeciﬁc symptoms derived from anecdotal accounts. and irritable bowel syndrome. there is insufﬁcient evidence to base any treatment on this possible deﬁcit. headaches (including migraine). Writing problems can include slanted writing. Helveston177 stated that there is no evidence that SSS exists and also that there is no basis to use the word “scotopic.203 Colored Lenses and Overlays At a national meeting in 1983. tic disorders..207 A multitude of different models have been used to explain the apparent “vi-
sual stress” and perceptual distortions that seem to occur in people with SSS. ﬁbromyalgia. and no formal experimentation. ADHD.207 In 1990. migraines. or attention deﬁcit (Helen Irlen. experimentally controlled studies to validate either the syndrome or the treatment ap-
. People with this syndrome are thought to suffer from perceptual dysfunctions that cause visual distortion. retinitis pigmentosa. personal communication. The only deﬁning characteristic is a reported beneﬁt of colored ﬁlters while reading. excessive daytime fatigue. and others. and visual fragmentation from sensitivities to particular wavelengths of light not attributable to ocular conditions. Before any supporting research. Proposed reading problems can include slow reading rate. autoimmune disease. Their alternative hypothesis involved the facilitation of attention. neurologic impairment. poor comprehension. July 17. which she originally called the “scotopic sensitivity syndrome” (SSS) (now also called the Irlen syndrome or the Meares-Irlen syndrome). there are no clearly established criteria for SSS. fatigue. The Irlen method uses colored lenses and ﬁlters to reduce the offending wavelengths and correct these perceptual dysfunctions but does not treat children or adults with language deﬁciencies. interest in colored ﬁlters or overlays as a treatment for dyslexia persists and promotion continues. perceptual problems. and tearing. recurrent automobile accidents.” because the photopic system is used for reading. the problem goes far beyond that of semantics. it was stated that specially prescribed tinted lenses may be an effective method for the treatment of a variety of reading disorders. Currently. complications from laser-assisted in situ keratomileusis (LASIK) and radial keratotomy. speciﬁc learning disabilities. including head injuries.177 For many. tinted lenses have been credited by multiple Irlen International newsletters with helping those who suffer from light sensitivity. shortened reading times. who noted that the Irlen techniques had received extensive media coverage without having data-based. to some degree. discomfort. ﬂuency. The initial claims of Irlen were based on observations. Irlen206 proposed treatment with tinted lenses for a speciﬁc group of adults with reading problems. anxiety disorders.177. On the program.177 This national exposure led to great interest in the treatment. students’ anecdotal accounts. Supporters of the Irlen syndrome contend that the syndrome affects. an author of the Iovino et al report.208 In 1990. visual stress. light sensitivity. including dyslexia. skipping words and lines.ings indicated that the magnocellular deﬁcit theory may need to be reexamined.210 the editor in chief. sensory integration disorder. reading in dim light. In addition to helping people read better. This result is important. and avoidance of reading. depression. cataracts. General symptoms can include headaches. To this day. and distortions associated with a wide variety of different problems. misaligning numbers. memory loss. 12% to 15% of the general population and 45% of those with learning problems. 2007).209 It is interesting that the January 2006 Irlen International Newsletter stated that 1 reason that the problem of SSS escapes ophthalmologists is that ophthalmologists typically test under dim-light conditions. The Irlen International Newsletter207 has reported that the Irlen syndrome should often be expected within the following clinical composites: bipolar spectrum disorder. This syndrome is postulated to interfere with overall attention. SSS was featured twice on the television program 60 Minutes. was also one of the authors who originally proposed the magnocellular deﬁcit theory of dyslexia. visual dyslexia. schizophrenia. concussions. the Journal of Learning Disabilities published 3 articles in a special series on use of the Irlen technique. A preface was written by Wiederholt. unequal spacing.208. dyslexia. LMFT. nausea. many experts question its validity. language deﬁcits. the magnocellular dysfunction theory and cortical excitability are being considered. school phobia. misreading
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words. burning eyes. MA. because Breitmeyer. Although Irlen and proponents of her method routinely refer to SSS as though it were an accepted medical syndrome. whiplash. multiple sclerosis. seasonal depression. and errors while copying. cranial cerebral trauma. macular degeneration. He also noted that reports of successful treatment of reading disorders using tinted lenses are based on anecdotal information and testimonials. At the present time. performance. mood disorder spectrum. chronic anxiety. Asperger syndrome. and comprehension and create symptoms similar to learning disabilities.
176. vision-therapy. The remaining subjects in the vision-therapy group showed a
. Thirtyeight of these participants were found to have optometric problems.211 Solan also noted that there was no optometric pretesting. Three of 11 in the vision-therapy group dropped out. but only 22 completed the study. in random order.FROM THE AMERICAN ACADEMY OF PEDIATRICS
proach. no control group was used.176. then followed by use of “optimum” lenses for the next 9 months. randomly and in an idiosyncratic manner. but no reading improvement or change in optometric testing results was noted. Subjects in the Irlen-ﬁlter group noted a reduction in SSS symptoms. Parker. this study was highly ﬂawed.212 In his review of the study.212 who studied poor readers with symptoms of scotopic sensitivity. Students who did not show scotopic signs were classiﬁed as nonscotopic.211 and Hoyt. the validity of the Irlen technique still had not been established.211 Most importantly. Because of the many weaknesses in this study. they did not show any preference for color and showed no symptomatic or reading improvement with the colored overlays. The subjects were assigned to an Irlen-treatment. He further stated that on the basis of these 3 studies and the literature before 1990. because the children underwent biased selection. and the treatment with the optimum lenses seemed to have no greater effect than the
PEDIATRICS Volume 127. no change.176 The small group size diminished the study’s statistical signiﬁcance. The Irlen-treatment group used Irlen lenses for 2 weeks and placebo lenses for 2 weeks. Thirty of the 38 originally chose to participate. and comprehension were signiﬁcantly improved when the scotopic children read with the preferred colored overlay. The subjects underwent pretreatment and posttreatment optometric and reading tests. The improvement in some of the subjects in the placebo-ﬁlter groups may have been attributable to the placebo effect. March 2011
semiplacebo. For the ﬁrst 3 months.213 The article’s conclusion stated that reading rate.209 The ﬁnding of regression may have been attributable to the unreliability or variability of the reading assessments. or control group. Solan noted that the improvement in reading was equivocal211 and that the use of gradeequivalent scores was misleading. the conclusion is not valid. and the subjects were divided into small groups. Parker concluded that the ﬁndings could not be considered statistically or scientiﬁcally valid.211 Dropping the 13 subjects in the study led Parker to explain that using the same or similar measures to deﬁne the treatment group and to assess the effects of treatment is “criterion contamination. because although they had scotopic complaints. the study subjects used an “intermediate” set of lenses based on the student’s ﬁrst preference.176 Reading measures varied between improvement. The study then included only subjects who tested positive for both SSS symptoms and vision problems. The second study was by O’Connor et al213 of 105 students from grades 2 to 6 who were reading below grade level. Solan. The third study. Parker noted that the study was very short.” The authors concluded that comprehension and accuracy but not reading rate improved using the optimum color lenses. and regression in 4 of 5
groups. the improvement in all reading measures seemed developmental. Number 3. These 3 studies were then reviewed in the journal by Parker. He stated that the consulting editors who reviewed the studies for publication noted signiﬁcant scientiﬁc and methodologic ﬂaws that created a signiﬁcant controversy as to whether the studies should be published in the journal. Hoyt recommended a long-term (over 1-year) prospective multicenter trial with carefully constructed control groups of children with learning disabilities who have an ophthalmic or optometric examination at the study’s onset and at least yearly thereafter.176 Furthermore. Optimum color lenses were identiﬁed after a 2-hour diagnostic procedure that involved up to 130 colors. the conclusion is not valid.”176 On the basis of examination of the methodology of this study. by Blaskey et al.209 In their reviews of these 3 Irlenﬁlter studies.209 and 12 of the 44 subjects reported changes in remedial coaching. Ninety-two children continued in the 1-week study. degree of assistance. Hoyt209 and Solan211 noted that the study authors stated that the participants had undergone optometric or ophthalmic examination within the year but did not provide the results. Students who displayed deﬁnite scotopic symptoms using the Irlen Differential Perceptual Schedule and displayed marked improvement in reading performance with a particular colored overlay were classiﬁed as scotopic. In his review. or an alteration in the learning/supportive environment. Three of 11 in the Irlen-treatment group preferred the placebo ﬁlter. accuracy.209. He also noted that the study only had a 50/50 chance of obtaining a statistically signiﬁcant ﬁnding because of the small study size (which was actually the best of the 3 studies). Thirteen subjects were dropped from the study. The use of the intermediate colors was expected to act as a “semiplacebo. Parker stated that the use of age scores was a major ﬂaw. The ﬁrst article in the series was by Robinson and Conway. Because ﬁrm conclusions could not be drawn. and Hoyt noted serious methodologic ﬂaws.214 included 40 participants from the ages of 9 to 51 years who were self-referred for a study on Irlen treatment.176 Solan.
216 Menacker et al217 performed a cohort study (the results of which were published in 1993) using 6 different colored lenses. Although symptoms were reduced in this study. Evans and Drasdo215 criticized the literature for having no sound theoretical basis for SSS and for the unscientiﬁc testing of precision tints. The study by Robinson and Foreman219 in 1999 also highlighted the need for proper control procedures. He reported that authors of some studies that used anecdotal comments and questionnaires reported improvements in symptoms of visual distortion.213 This group with Irlen symptoms showed a high percentage of convergence and accommodative dysfunction. including the placebo group. In 1991. they have not been supported by significant gains of reading achievement in controlled studies. Both the precisiontint and placebo-control groups showed a reduction in symptoms of SSS. and the 3 experimental groups. Parker176 challenged the statistics in the study and stated that the probability of ﬁnding a statistically signiﬁcant result when none existed was unacceptably high.219 In 2002. The remaining control group was too small to be of any significance.218. 1 neutral-density lens. but a larger effect occurred in the group that used prescribed colored ﬁlters.213 This ﬁnding highlighted the need for a formal deﬁnition of SSS. Robinson216 reviewed the literature concerning tinted lenses and ﬁlters up to 1993.reduction in SSS symptoms and improvement in optometric testing but improvement on only 1 of 4 reading subtests. Subjects also perceived an improvement in their SSS symptoms regardless of whether they were wearing placebo tints. blue. Authors of past studies have remarked that the symptoms of SSS seem similar to convergence insufﬁciency. Bouldoukian et al220 reported on subjects who experienced SSS symptoms while reading and concluded that colored overlays improved reading speed. demonstrated signiﬁcantly more improvement than the controls. overall. the effect of heightened expectations cannot be eliminated because of the lack of a control group. The main ﬂaws in this study were that multiple treatments were given to the Irlen-treatment group and the unacceptably large loss of subjects.218 Subjects who experienced headaches or eye strain in addition to reading difﬁculties were chosen. However. and an empty spectacle frame and showed no reading-performance change or preferred tint among disabled readers. In many studies with positive results.226 Also. Robinson concluded in his review that improved print clarity may make the learning of word-attack skills more effective but will not teach such skills and must be accompanied by reading instruction when needed. The few noncontrolled studies that he reviewed showed evidence of inconsistent ime840 FROM THE AMERICAN ACADEMY OF PEDIATRICS
provement in variable subskill areas of reading. but it was stated that they showed no change in vision status or symptoms or on any of the reading measures.211. the results also revealed that greater than onethird of the subjects preferred the control ﬁlter and. Spafford et al221 found that contrast reduction. permitted poor readers to be diagnostically differentiated from proﬁcient readers. Robinson also noted that some studies with positive results were unable to be duplicated. this study’s results suggested that some of the effects of colored lenses may not be entirely attributable to placebo.209. Lightstone et al222 stated that the choice of color must be child-speciﬁc and requires trial and error. Although those survey studies have produced a high rate of positive anecdotal comments. the subjects were not signiﬁcantly more likely to prefer their colored overlay than the control ﬁlter. which challenges the claim that the symptoms of SSS are not attributable to vision abnormalities. The study included a control group (no SSS and no ﬁlter) and 3 experimental groups (placebo. Multiple different methods have been used to select the lens or ﬁlter color. blue tints.223–225 Color selection has shown considerable variability224 and poor test-retest consistency. accuracy. the tint selected needed to be changed in up to 25% of subjects within 1 year in a study by
. In 1994. One study showed initial positive gains in reading that were not sustained at retesting. and comprehension were not
affected by either the prescribed or placebo ﬁlters. All 4 groups showed increased accuracy and reading comprehension. Although the contribution of placebo effects was not entirely ruled out. Many studies found no signiﬁcant improvement in reading when using colored ﬁlters. This study measured the effect of Irlen ﬁlters on reading performance as well as students’ perception of their academic ability.208. Five of the 8 control subjects dropped out.211. Wilkins et al218 conducted the ﬁrst double-masked placebocontrolled study to test the effect of colored ﬁlters on symptoms of SSS and reading performance. and precision ﬁlters). reading rate.208.219 This study revealed a likely placebo effect not only on subjective symptoms but on actual reading performance. Serious methodologic ﬂaws have continued to be noted in subsequent SSS studies. Another study claimed that the positive effects may have been confounded with other remedial interventions given at the same time. which invalided the study. but not lens color. or prescribed tints.
and 233–236. In 1999. 111. 176. Despite the continued lack of deﬁnitive evidence of its effectiveness. Worrall et al182 noted that the studies indicated that fewer than 5% of readers who experience discomfort beneﬁt from a change in contrast. 166. Since 1990.
†††Refs 111. the efﬁcacy. the blue background provided improvement in the reading rate in low-contrast conditions. but deeper analysis of the statistics revealed a question of signiﬁcance. Scientiﬁcally.233–235 but a few studies have reported partial positive results.††† Some studies have claimed to detect some improvement in a few patients in 1 reading subskill but not in other areas. 1 Irlen center director stated that it is equally the responsibility of others to carry out this validation research.177 Behavioral Optometry Skefﬁngton was the director of education of the Optometric Extension Program from 1928 to 1976. colored lenses and ﬁlters continue to be promoted. convergence.228 Solan et al229 found that comprehension of poor readers was improved by using blue ﬁlters. and 215.
colored ﬁlters and lenses may be ineffective. 211. except that they act as a placebo.213.231 Many unreported studies have shown no effect of colored ﬁlters on measures of either reading performance or SSS symptoms.214. Also. 217. 208. remediation for underlying reading problems will still be required.FROM THE AMERICAN ACADEMY OF PEDIATRICS
Stone. Not only are some ﬁndings less meaningful than they ﬁrst appear.216. 178.232. Thus. even proponents of precision tints have maintained that although an improvement in print clarity may facilitate the process of learning to read.224.222. improvements in reading subskills do not necessarily translate into improvements in reading. small sample size.212. study results have been inconsistent208. and largely negative results does not support the effectiveness of tinted lenses and tinted ﬁlters in these patients. 215. or color on the page beyond what would be expected from a placebo treatment alone. Such ﬁlters have been successfully produced but have rarely been implemented in Irlen-lens research. including biased sample sePEDIATRICS Volume 127. March 2011
lection. techniques. However. Many studies include control groups. ‡‡‡Refs 14. With nothing but a small amount of anecdotal evidence.227 In a study by Croyle. therefore. 205.218.208 Rooney238 advised the education community not to embrace SSS and its treatment for learning disabilities and dyslexia. Contrary to usual scientiﬁc practice. In a study of yellow ﬁlters by Ray et al. the burden of proof is on the developers and promoters of the Irlen method to provide strong evidence to show that their diagnosis is valid and their treatments are beneﬁcial. Iovino et al205 found that blue transparencies significantly improved reading comprehension but reduced reading rate. Overall. and insufﬁcient control for the placebo effect to support the assertion. 208. whereas the blue background had a slight deteriorative effect under high-contrast conditions. 209. brightness. Thus. The positive evidence for the effects of colored overlays and ﬁlters on reading performance is limited. 209. among other things. but they are typically composed of children who use no ﬁlters during testing and who report no symptoms of SSS. the medical community has recommended that Irlen promoters design and perform rigorous prospective. if any.205. heightened expectations. Evans237 explained that treating visual problems or perceptual symptoms will likely alleviate only the “visual component” of reading problems and will not impact the phonologic deﬁcits underlying most cases of reading disabilities. combination with traditional remediation techniques.239 The Skefﬁne841
.‡‡‡ Contrary to the broad claims of many Irlen-treatment proponents that the syndrome is highly prevalent in the reading-disabled population. many studies have shown that colored overlays and ﬁlters are ineffective. it is not enough to lead to spontaneous improvements in word-recognition skills and other complex elements of reading. and reading rates. CBS reported Irlen’s claims to the public and circumvented the normal process of scientiﬁc review and debate.223. the inclusion of placebo ﬁlters of similar color to precision tints but outside the effective range of chromaticity.231 the conclusion stated that there was improvement in accommodation.208 More recent published studies advocating the use of these therapies to treat reading difﬁculties have continued to have serious ﬂaws in their methods. masked. biased interpretation. Among the numerous criticisms of Irlen’s treatment is the argument that precision tints are highly susceptible to placebo effects.208 Results are inconclusive when placebo ﬁlters are not implemented. 214. of this approach seems to be limited to a small subgroup of children with reading problems. By relying on anecdotal accounts or experiments that lack adequate placebo controls. whereas Christenson et al230 found no signiﬁcant difference in reading comprehension or reading rate when using blue ﬁlters.217. Controlling for placebo effects requires. 223. 177. it does not adequately control for the possibility of placebo effects. Number 3. controlled scientiﬁc studies to document the effectiveness of their method. many of the studies cited as proof of Irlen-lens efﬁciency actually have been found to be inconclusive after deeper analysis. Although this is a form of control. interpretations of ﬁndings are speculative at best. the large variability in the methodology. 112.
126. Hendrickson stated that every child would beneﬁt from the use of “learning glasses” in the classroom.00 D) training lenses for 6 to 15 months and found no signiﬁcant difference in reading comprehension. The optometric literature has implicated accommodative spasm.00 D. visualmotor integration. and (3) visual information-processing skills of visual discrimination. The model further states that this esophoria is best treated preventively.50 to 1.124.247–250 The authors of most of these studies claim that patients experience visual symptoms that lead to degradation in reading performance. they are used to teach the eyes to relearn distance-vision skills that have atrophied. Behavioral optometrists believe that training lenses help the visual system develop and mature normally. They are frequently used in conjunction with vi-
sion training. Skefﬁngton240 stated that they are best prescribed preventively before a visual problem is identiﬁed. ill-sustained accommodation. Ophthalmologic and optometric clinical studies have shown that the average near ocular alignment is approximately 1 prism diopter of exophoria.50 D lenses near prescriptions in young adults and found no signiﬁcant difference in visual performance.262 Greenspan253 showed improvement in pencil-and-paper visual tasks and reading posture with the low-plus lenses.” not a norm.261. decreased attention span.242 The “expected value” is an “ideal value. binocularity. Practitioners have followed several highly variable methods to establish the dioptric value of the near correction.239 Skefﬁngton’s model states that binocular anomalies and refractive errors are not primary conditions but products of underlying near-point stress. and ﬁgure-ground perception. and binocular dysfunction as being linked with reading disorders. refraction. Esophoria usually develops. accommodative insufﬁciency. The justiﬁcation and beneﬁt for routine in-
.240 His theories were derived exclusively from his and his collaborators’ (Harmon and Renshaw) clinical experience and never independently refereed or formally debated outside the Optometric Extension Program. visual closure.50 to 1. daydreaming. Many children with typical latent strabismus have been labeled by developmental optometrists as abnormal and diagnosed with near-point stress and a “relative esophoria” if they show physiologic lower values of exophoria than their “expected value.242 The Optometric Extension Program “expected value” for ocular alignment at near for children is 6 prism diopters of exophoria. There is no proof of cause and effect between decreased binocular function and symptoms or between symptoms and poor reading.243–246 Using diagnostic criteria that are not valid such as the developmental optometric “expected values” will lead to misdiagnosis of many conditions.241 The results of each test are then noted to be higher or lower than an “expected” value. Most people free from ocular symptoms have small amounts of latent strabismus (esophorias or exophorias) that should be considered physiologic.gton near-point stress model is the basis for much of behavioral optometry. Other studies have been unable to ﬁnd an increase in the incidence of binocular disorders in children with reading difﬁculties or an association between motility disorders and reading ability.116. and ocular motility. Keller and Amos263 critically reviewed Greenspan’s data and found the effect of the developmental lenses to be insigniﬁcant.253–256 Grisham et al257 reported an increased incidence of various symptoms in slower readers but could not show a signiﬁcant difference in reading ability between readers with normal and abnormal binocular function.258 It has been argued that treatment of accommodative dysfunctions with lowpower reading lenses will eliminate secondary problems and their associated symptoms and thereby improve reading efﬁcacy.259. accommodative inertia.111. Wildsoet and Foo265 compared 13 children who wore plano lenses and low-power ( 0. Harmon’s theories concern reading posture. it would imply some unique property of the 0. but sometimes exophoria or myopia develops from the stress. proposed by Scheiman247 divides evaluation and treatment into 3 categories: (1) visual acuity. Skefﬁngton recommends an examination using 21 procedures for every patient in a standard sequence.”
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A recent model of vision. (2) visual efﬁciency skills of accommodation.113. considerably different than the traditional optometric model.127 Training Glasses “Training” or “developmental” lenses are low-plus power glasses to be used for reading to relieve stress. They generally have a power of 0. visualization. Keller and Amos also noted that if there is an effect. increased heart and respiratory rate.249–252 Accommodative disorders are implicated in causing print blurring. The model states that near-work stress causes underaccommodation and overconvergence. A study by Barry and Cochran264 compared plano (no power) and 0. visual memory. Beauchamp266 discussed the issue of overprescription of spectacles in his review of vision training in 1986. and poor posture.50 D lens regardless of the patients’ refractive error.260 Although they do not provide best-distance visual acuity. and eye health disorders. and some incorporate bifocals or prisms.
Keogh stated that.266. Number 3. Beauchamp stated that spectacles are provided to the vast majority of children undergoing optometric vision training despite the demonstrably low incidence of ocular motility or refractive deﬁcits. She noted in her 1985 review that the necessary and sufﬁcient components of vision training are unspeciﬁed and. visual memory. and. Developmental optometrists divide vision therapy into 2 broad categories: classic orthoptic techniques and behavioral or perceptual vision therapy. eye-movement and eyehand coordination training techniques are used to improve learning efﬁciency by improving visual processing skills. March 2011
ing the person to be more responsive to educational instruction. Behavioral vision therapy is based on the premise that differences in children’s visual-perceptual-motor abilities exist and that these perceptualmotor abilities inﬂuence cognitive and adaptive skills such as reading. which led to her second review. visual processing. Orthoptic techniques are used to correct accommodative and convergence dysfunctions as well as heterophorias and refractive errors that might be responsible for asthenopic symptoms (eye fatigue and discomfort often aggravated by close work). Olitsky and Nelson111 stated that there is no proof that there is a difference in accommodative ability between normal and abnormal readers and that there was no correlation between reading performance and any speciﬁc type of refractive error. visual closure.and readingdisabled pupils.111 In a critical review of the behavioral optometric literature before 2000 for the UK College of Optometrists. In 1974. in the 10 years after her ﬁrst review. writing. and the American Academy of Optometry formulated the following policy statement: “Optometric intervention for people with learning related vision problems consists of lenses. and nonverbal learning disorders. and vision therapy. Keogh and Pelland also noted that the nature of the relationship between vision. it seemed paradoxical that vision training was being recommended and used for a broad range of problems including preventive treatment. optometrists accept a link between poor reading
. and that the professional literature was characterized more by opinion than evidence. Keogh269 stated that the research on vision theory was sparse. It has been recommended to improve visual skills and processing in the belief that they will improve learning disabilities. These visual processing skills include visual-spatial orientation skills. Keogh and Pelland267 stated that after detailed review of more than 35 program descriptions. Furthermore. including hyperopia or a need for glasses. thus. They noted that the variation in visiontraining programs was so great that it was extraordinarily difﬁcult to draw inferences about the effectiveness of the procedures. Olitsky and Nelson noted that the very low power of the reading glasses or bifocals that are often prescribed throws further doubt on their usefulness in a child who often shows large amplitudes of accommodative ability. untested.124. Although much of the research basis for behavioral optometrists’ interpretation was completed before 1975. The 1974 review concluded with the observation that there was a lack of substantive and comprehensive evidence on which to make decisions about program effects and called for research to specify child and program characteristics that contribute to intervention outcomes. In behavioral vision therapy. behavioral optometrists continued to offer and expand vision training to learning. and motor activities used in activities of daily living.267 Blika124 found that one third of children in his study had unnecessary glasses. prisms. and visual-motor integration. thereby allowPEDIATRICS Volume 127.112 Vision-Therapy Literature Review Two major reviews of the visiontraining literature were undertaken by Keogh. reading.”268 A visiontherapy program consists of in-ofﬁce and at-home exercises performed over weeks to months and may include training glasses. including speech and language disorders. in 1974 and again in 1985 with Pelland267. Jennings239 declared that the literature revealed no convincing experimental evidence of any beneﬁts from a lowplus prescription. in general. Vision therapy does not directly treat learning disabilities or dyslexia. and many had improper prescriptions. the American Optometric Association. and learning problems continues to be a troublesome theoretical question that has not been well answered by optometrists involved in vision training. A task force representing the College of Optometrists in Vision Development. which led to the comment that there were almost as many training programs as there were vision trainers.269 to answer the questions of what optometric vision training is and for whom vision training is appropri-
ate and effective. visual discrimination. Vision Therapy Vision therapy is an attempt to correct or improve ocular.127. Behavioral vision therapists claim to improve the efﬁciency of eye movements to improve scanning and locating. fragmented.FROM THE AMERICAN ACADEMY OF PEDIATRICS
tegration of costly spectacles into the program is unsupported and often not discussed. a professor of special education. Vision therapy is a treatment to improve visual efﬁciency and visual processing.126. for the most part. and visual-perceptual disorders. methodologically ﬂawed. there was not a single prototypic program model.
116 Levine. randomized. In 1987. during a course of vision therapy. The American Academy of Ophthalmology recommended that appropriately designed and methodologically rigorous scientiﬁc studies with a team approach using multidisciplinary educational specialists be conducted to assess the effectiveness of vision therapy. He recommended properly designing research on the use of vision training for learning disabilities. and analysis of medical literature of the safety and efﬁcacy of medical technologies. Children included in the studies had been diag-
nosed with learning disabilities by using different criteria and may have been misdiagnosed or may have had additional conditions that confounded the ﬁndings. Beauchamp and Kosmorsky122 extensively reviewed the interdisciplinary literature for the history of dyslexia and its relationship to neuropathology and eye movements. In their review. They found that refractive abnormalities. remarked on the poor methodology in the reviewed studies. In addition. They concluded that eye movements are not the controlling factor in dyslexia or learning disabilities but are secondary to the comprehension difﬁculties. Metzger and Werner116 reviewed the ophthalmologic. ocular motility. No wellperformed randomized controlled trials (level I evidence) were found in the literature. because visual-perceptual problems do not underlie dyslexia. In most of the reported studies the data were ambiguous with equivocal ﬁndings so that the importance of visual efﬁcacy was undeterminable. Their literature review revealed that visual-perceptual training seems to be ineffective and that controlled evidence for treatment efﬁcacy has been found to be conceptually ﬂawed.270 The Institute for Clinical Systems Improvement reports are designed to assist clinicians by providing a scientiﬁc assessment.112 This report reviewed the literature on vision therapy for reading disabilities and concluded that there seems to be no consistent scientiﬁc evidence that supports behavioral vision therapy. They concluded that it is imperative that vision-training research receive systematic and rigorous testing and that the research be reported for review in a broader scientiﬁc arena. Two ophthalmologists and 2 optometrists were included on the panel on the topic of vision therapy. They declared that to focus on a single aspect of learning problems and to interpret an association or relationship as if it has causal implications goes beyond the evidence. scant. and perceptual capabilities did not differ between reading-disabled children and those with no reading disability. and psychological literature on the use of visual training for reading disabilities. review.and convergence inefﬁciencies. and near and distance phorias. they concluded that approaches designed to improve visual perception by training are misdirected. The vision-therapy studies have shown an absence of a standard deﬁnition of the techniques that constitute vision therapy. thorough search. farsightedness. accommodation. or colored overlays and lenses as effective treatments for learning disabilities.267 Keogh and Pelland stated that if visual processing problems are not the cause of many reading problems. They recommended that these trials include clearly deﬁned patient populations. The results of subsequent studies have been inconsistent and have failed to reproduce many of these ﬁndings. narrow interpretation of the ﬁndings.267 In 1984. strabismus.128 in his commentary on their article. Thus. amblyopia. they noted signiﬁcant ﬂaws in experimental methodology that supports the visually based hypotheses.112 The Institute for Clinical Systems Improvement technology assessment report on vision therapy was published in 2003. and an initial preconception that a factor in isolation causes reading disability. They found little deﬁnitive evidence for the effectiveness of vision therapy even when the results were aggregated across studies and concluded that using this treatment would lead to wasteful and ineffective intervention efforts. Their conclusions were that the studies of vision therapy are predominantly poor-quality case series that provided inadequate scientiﬁc evidence to enable a conclusion to be reached about the efﬁcacy of vision therapy for patients with learning disabilities. orthoptic vision therapy. optometric. children were simultaneously receiving continued and even enhanced instruction in a standard or remedial educational setting and undergoing natural maturational changes. or accommodative disorders. and contradictory. many optometrists argue in favor of vision therapy for problems of convergence. The reports classify and grade references by their level of evidence. researchers having a vested interest. ocular motor abnormalities. convergence insufﬁciency. vision training to improve visual efﬁciency is not the treatment of choice. Furthermore. Keogh and Pelland reported that most of the reviewed studies did not meet rigorous research standards. Complementary Therapy Assessment: Vision Therapy for Learning Disabilities was published in 2001 by the American Academy of Ophthalmology. controlled trials of vision therapy for these potential uses. and binocular fusion. They also found that visual-motor-perceptual training programs produced no further improvement in reading ability for affected
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children when compared with those in control groups. control
. The committee encouraged masked.
Eight of the 15 patients. and recession from a target. Results for the entire group showed no signiﬁcant between-group differences for all educational tests. masked.164 in his accompanying editorial. Granet. because fewer actual hours of treatment were received. orthoptic therapy prescribed by pediatric ophthalmologists and orthoptists consists of push-up exercises using an accommodative target of letters. The exercises are performed at home. numbers. Sixteen of his 20 patients (80%) reported complete resolution of symptoms and were objectively “cured” using the same criteria as in the study. and the children are reevaluated in the ofﬁce on a monthly basis. The criteria for study inclusion was a near exophoria at least 4 prism diopters greater than at far. noted that neither home-based treatment group used in this study was an ideal comparison group. In 2005. stereogram convergence exercises. Number 3. at the conclusion. The Convergence Insufﬁciency Treatment Group study showed better improvement with intensive ofﬁcebased vergence/accommodative and home reinforcement therapy compared withlessintensivehometreatmentsorplacebo. clearly deﬁned treatment programs.273 a site principle investigator for the study.161 in his accompanying editorial. ofﬁce-based orthoptic vision therapy with home reinforcement. Diagnostic educational testing took place before the study. placebo-controlled. and a minimum symptom score. Symptomatic improvement was noted in 43% of the home-based pencil push-up exercises group.160 The Convergence Insufﬁciency Treatment Group study showed that convergence insufﬁciency can be improved with in-ofﬁce vision therapy. March 2011
Treatment Group published data from a small.161. a receded near point of convergence. or 53% of the patients treated with ofﬁce-based vision therapy. Two examples are: (1) Do your eyes
. or pictures. The control group received a placebo program that provided similar amounts of individual time with the children. Although the convergenceinsufﬁciency symptom survey has undergone validation.FROM THE AMERICAN ACADEMY OF PEDIATRICS
groups. which was a ran-
domized clinical trial comparing home-based pencil push-up exercises. randomized clinical trial that showed that patients treated with ofﬁce-based vision therapy improved more than those treated with minimally intensive home-based pencil push-up exercises or placebo. A 2005 Association for Research in Vision and Ophthalmology abstract by optometrists Sampson et al272 discussed a randomized. Using these diagnostic criteria may overestimate convergence insufﬁciency. Generally. multicenter.”165 Kushner. were considered symptomatically “cured. The experimental group underwent a visual training program designed to be typical of programs used in pediatric optometric practice. 33% of the home computer vergence therapy group. Another major criticism of the 2 studies is the deﬁnition of convergence insufﬁciency. Both groups made signiﬁcantly greater postintervention progress on most variables compared with that expected had no intervention occurred. The review concluded that the results of small controlled trials and many case reports support the use of eye exercises in the treatment of convergence insufﬁciency but that there is no clear scientiﬁc evidence published in the literature to support the use of eye exercises in the remainder of the areas reviewed. Wallace. home computer vergence therapy. masked.274 many of the symptoms in their symptom-scoring system are too vague and repetitive. insufﬁcient positive fusional vergence at near or minimum positive fusional vergence. including learning disabilities and dyslexia. jump-to-nearconvergence exercises. and adequate patient follow-up to determine if any observed beneﬁts are maintained. surveyed 20 pediatric ophthalmologists and 15 orthoptists who treat convergence insufﬁciency. and 6 months after the completion of the programs.165 The Convergence Insufﬁciency Treatment Group163 published a larger second study in 2008. He stated that the difference between treatment groups could have easily been affected if the time in true treatment had been equalized. Thus.165 The study used both ﬁndings and a symptom score. His survey revealed that most pediatric ophthalmologists and orthoptists do not use unmonitored home treatment with pencil push-ups. and controlled study of 96 suboptimally achieving children who showed visual information-processing delay and normal auditory/verbal language development.270 Rawstron et al271 published a literature review of eye exercises in 2005. 75% of the ofﬁce-based vision therapy with home reinforcement group. results for the entire group did not provide evidence to support efﬁcacy of the visual training program under investigation. relevant outcome measures. wrote a letter to the editor concerning the methodology of the study. and 35% of the ofﬁce-based placebo therapy with home reinforcement group. push-up exercises with additional base-out prisms. which suggests that a placebo effect was responsible for much of the demonstrated improvement. Kushner retrospectively reviewed his last 20 patients with convergence insufﬁciency treated with these orthoptic techniques. and the home therapy was less intensive. the Convergence Insufﬁciency
PEDIATRICS Volume 127. and ofﬁcebased placebo therapy with home reinforcement in 221 children in a 12-week study. but the accompanying editorial revealed that properly prescribed and monitored home treatment is also very effective.
Barrett reviewed evidence in 10 categories: accommodative/ vergence disorders. His report concluded that the continued absence of rigorous scientiﬁc evidence from welldesigned trials to support behavioral management approaches. He concluded that the merits of vision therapy are extremely difﬁcult to assess and that there is a lack of controlled studies to support behavioral management strategies. therapy to reduce myopia. This problem was noted in the editorials161. the lack of sound evidencebased research supporting this stance will always leave it open to the criticism that all it does is pay attention to a perceived problem and thereby inﬂuence its expression. The basic tenet of their hypothesis is that children with reading disorders have an increased incidence of vision abnormalities. underachieving child. In his review he noted that many studies showed methodologic and statistical weaknesses. prisms for near binocular disorders and for producing postural change. many people without convergence insufﬁciency may have a symptom score that qualiﬁes them for the study. training central and peripheral awareness and syntonics. the 2008 study is weakened.hurt when reading or doing close work? and (2) Do your eyes ever feel sore when reading or doing close work? Also. low-plus lenses at nearto-slow myopia progression. He also questioned whether improvement on the training task would transfer to routine activities. On behalf of the UK College of Optometrists. complaints such as eyestrain and headaches have been found to be poor markers of eye conditions in young children. therapy of amblyopia and strabismus. Jennings239 reviewed behavioral visione846 FROM THE AMERICAN ACADEMY OF PEDIATRICS
therapy studies for the UK College of Optometrists. This is because many of the patients that behavioral optometrists are treating would not exhibit any abnormality under clinical assessment using traditional optometric approaches. and neurologic disorders and neurorehabilitation after trauma/stroke. His report on the evaluation of the theory and practice of behavioral optometry was published in 2000. He commented that careful study design is essential.275 in his letter to the editor. In a separate study. Barrett276 in 2009 reviewed studies of vision therapy published since the Jennings report in 2000.277 Summary on Vision Therapy Some optometrists attribute reading disabilities or a portion of them to 1 or more subtle ocular or visual abnormalities. noted that sustained convergence should have been stressed in performing the home pencil push-up exercises. the use of symptoms in children may be unreliable.276 A 2009 article in Optician Online commented on Barrett’s study. Two examples are: (1) Do you read slowly? and (2) Do you have trouble remembering what you have read? Using this symptom survey. The clinical editor of Optician Online stated that although some practitioners may be convinced from their own experience of the effectiveness of behavioral optometry. He reported that vision therapy cannot currently be considered as an evidencebased treatment for reading or learning disorders. Jennings’ conclusion was that behavioral optometric therapies do not satisfy evidence-based scrutiny. represented a major challenge to the credibility of the theory and practice of behavioral optometry. Methodologically. Barrett remarked that the theory and practice of behavioral optometry remain controversial. Finally. and the paucity of controlled trials in particular. The editor contended that it seemed less than ethical to charge for such interventions under a cloak of clinical practice until good evidence for the techniques exists. The comparison group should consist of the home exercise methods that are frequently prescribed by pediatric ophthalmologists or orthoptists and should be for the same number of hours and intensity as the in-ofﬁce vision therapy. because it included 2 different variables and compared different treatments and 2 different intensities of treatment. Treatment with minimally intensive pencil pushups is not representative of the standard of care and. sports vision therapy. The College of Optometrists in Vision Development estimates that more than 60% of prob-
.164 that accompanied both the 2005 and 2008 convergenceinsufﬁciency treatment studies and also in a letter to the editor by Granet.156 The apparent superiority of ofﬁcebased orthoptic vision therapy over home-based exercises in these 2 studies is not as strong as it ﬁrst seemed. Sethi. especially when considered from the perspective of the traditional optometrist. because with training and practice. Barrett’s ﬁnal conclusion was that these approaches were not evidence-based and could not be advocated. many of the symptoms used in the symptom score are nonspeciﬁc. does not provide the appropriate comparison. He declared that the large majority of behavioral management techniques were to be considered unproven until more rigorous trials were undertaken. This improvement would be greatest if the patient is encouraged and reinforced. perceptual judgments improve. near-point stress and low-plus prescriptions. thus. Barrett found that vision therapy for conver-
gence insufﬁciency seemed to have some beneﬁts but that further largescale controlled trials that used proper controls were needed.273 The major weakness of these studies was that the study groups were not appropriately chosen to provide a proper comparison.
Proponents of vision therapy claim that treatment of these visual abnormalities will help children with learning disabilities be more responsive to educational instruction. 166. 270.128. a variety of criteria have been used in diagnosing subjects included in the study. muscle exercises.153. approaches designed to improve visual function by training are misdirected. anecdotal information. 116.### In general. 152. and ophthalmologists. 134– 137. 239. 24. 119–128. 152. ¶¶¶Refs 118–121. these research methods and references show poor scientiﬁc validation.271 Scientiﬁc evidence does not support the claims that visual training. many reviews of the literature that optometry uses to support vision therapy have been performed. 14. 266. 136. or nonedited or loosely reviewed publica149–151. 239.267 Currently. 270. 267. However. as well as the signiﬁcance of any association. and a variety of treatment programs have been used within a study. 122. 119–128. children with dyslexia or related learning disabilities have the same visual function and ocular health as children without such conditions.
PEDIATRICS Volume 127. jerky eye movements. ﬂyers.137. furthermore. 127. 239. the association of binocular and other vision anomalies with learning disabilities. 82. 178. 29. 136. 178. Often. 205. subtle or severe eye defects do not cause decoding or comprehension difﬁculties. 178. the investigator often has a vested interest in the outcome of the study. 9–12. Many of the detailed reviews that scientiﬁcally questioned the credibility of the theory and practice of vision therapy have been performed recently by optometrists. but this hypothesis has not been proven scientiﬁcally. 128. and
is important to have adequate eyesight and ocular motility to read with the greatest efﬁciency. visual-motor dysfunction. 116. ****Refs 14. 166. no consistent relationship between visual function and academic performance and reading ability has been shown. Also. In addition. there is inadequate scientiﬁc evidence to support the view that subtle eye or visual problems.270. 270. 154. can often be explained by the placebo effect. Many claims supporting vision therapy are old or found in newsletters. because most of the information has been of poor statistical and scientiﬁc quality. 153. 239. Many of the references used to support the claims in these articles do not relate directly to the topic. 111–113. and 276. 122. 136. Many of the studies that support vision therapy use small numbers.181. 266. Because visual problems do not underlie dyslexia. 128.266. Many children without vision problems have been labeled as abnormal. 153. 233–235. selfreports. maturation changes. Optometrists also claim that visual dysfunction in children impairs their ability to respond to the speciﬁc instruction intended to remedy the disability. or hypothetical difﬁculties with laterality or “trouble crossing the midline” of the visual ﬁeld. and 278. Many authors in the optometric literature proclaim the usefulness of vision therapy for reading and learning disabilities. and colored lenses and ﬁlters are effective direct or indirect treatments for learning disabilities. including abnormal focusing. 44.122. 214. 34.112. behavioral/perceptual vision therapy. 123. 266. and 278. 276. prisms.267 Optometric vision training is based on the premise that reading is primarily a visual task.239. 122. 116. increased time and attention given to students who are poor readers. 208. 266. 266. 128. training glasses. the nature of the relationship between vision problems and reading and learning problems continues to be a troublesome theoretical question that has not been answered adequately by optometrists involved in vision training. 26. This claim has not been scientiﬁcally established.270. cause or increase the severity of learning disabilities.62. 149–151. and 276. 29. because typical physiologic latent strabismus is not taken into account. 116. Studies have been poorly designed. 166. 166. and 276. ††††Refs 14. which makes evaluation of the claims of successful treatment difﬁcult to analyze. and 266. ‡‡‡‡Refs 111–113. 116. 136. 153. Thus.182. Reviews of the vision-therapy literature revealing a lack of scientiﬁc support have been performed by researchers in reading and education. 134. 24–26. 267. Refs 2. ocular pursuit-and-tracking exercises.**** There is no valid evidence that children who participate in vision therapy are more responsive to educational instruction than children who do not participate.FROM THE AMERICAN ACADEMY OF PEDIATRICS
lem learners have undiagnosed vision problems that contribute to their difﬁculties. 239. has not been scientiﬁcally demonstrated. 31. and used inadequate or poor controls so that bias and placebo effects may have confounded the results.§§§ Statistically. 134–138. 124. and testimonials. books without research.¶¶¶ Although it
§§§Refs 14. March 2011
tions. and they typically rely on case studies. Number 3. or the traditional educational remedial techniques with which they are usually combined. 270–272. 267. failed to “mask” the investigator.276 Detailed review of the vision-therapy literature has revealed signiﬁcant weaknesses.” Over the last 35 years. 126. 270–272. binocular dysfunction. perceptual dysfunctions. 15. 111–113. 271. 178. 267.‡‡‡‡
###Refs 111–113. pediatricians. Visual problems may coexist with dyslexia but seem to be present with the same incidence as in the population in general. 111–113. 34.†††† The reported beneﬁts of vision therapy. including nonspeciﬁc gains in reading ability. 39. 111–113. misaligned or crossed eyes. 135. 267. many of the abnormalities that are said to cause problems with reading are undeﬁned and unspeciﬁed. 116. It is even more difﬁcult to determine any possible beneﬁt of vision therapy when used “preventively.
43. 24. Continuing critical litera§§§§Refs 12. learning disabilities have spawned a wide variety of scientiﬁcally unsupported vision-based diagnostic and treatment procedures. 60.34. and may delay proper instruction or remediation. 209.166 The primary care pediatrician and ophthalmologist should not diagnose learning disabilities but should provide information on learning disabili¶¶¶¶Refs 1. syntax. Outcome studies documenting effective results using EBM are necessary before vision therapy can be recommended. and that their treatments are beneﬁcial. psychologists. memorization of sight words. over the last half-century in many thousands of children with learning disabilities and also as a “preventive treatment.#### Later. vocabulary instruction. early identiﬁcation. 63– 65. even if reading difﬁculty is not the chief complaint. 270–272. Children with learning disabilities and possible visual problems suspected by their parents. masked.¶¶¶¶ Most programs include daily intensive individualized instruction to explicitly teach phonemic awareness and the application of phonics.
commodations. the primary care provider should refer the child for early evaluation and intervention.25. 177. teachers. Cost-effective prevention.
Parents should read aloud to their children to help develop language skills. but treatment of convergence insufﬁciency by any method is not a treatment for dyslexia. 128. 122. convergence and/or focusing deﬁciencies. 111–113.154 Treatable ocular conditions include strabismus. 178. 14.55 Comprehension is gained through ﬂuency training. may waste family and/or school time and resources. If early warning signs of learning difﬁculties are detected in preschool-aged children by parents or teachers or during developmental surveillance or screening. because some of these children may also have a treatable visual problem along with their primary reading or learning dysfunction. Because they are difﬁcult for the public to understand and for educators to treat. Evaluation for learning disabilities should be considered for all children who present with school difﬁculties. The IEP should describe what services will be needed.§§§§ Despite the continued lack of deﬁnitive evidence of its effectiveness. including speciﬁc remedial interventions and ac-
FROM THE AMERICAN ACADEMY OF PEDIATRICS
. The remedial program should be individualized. 217.
ture review will ensure that the best evidence is disseminated and poorquality studies are subject to proper scrutiny. 166. and which type of program would be best and should set guidelines for measuring future educational progress.34. 116. The ophthalmologist should identify and treat any signiﬁcant visual defect according to standard principles of treatment. amblyopia. the optometric claims that vision therapy improves visual efﬁciency cannot be substantiated. and refractive errors. 30–35. 152. ﬂuency training. 267.24. and 81. the medical and educational communities have recommended designing and performing rigorous prospective. vision training for improving visual efﬁciency and visual processing has been widely used. These ineffective. 32–35.110–113. and 63– 65. 223. Early identiﬁcation of children who show delays or difﬁculties should be a high priority for elementary school teachers. that an association exists between visual dysfunction and learning disabilities.153.167 To outline the educational goals and services that the student needs to be successful. Treatment of convergence insufﬁciency helps the reader maintain visual effort for prolonged reading. 205. Making the correct diagnosis of the speciﬁc type of learning disability along with any comorbid conditions is of paramount importance before any therapeutic regimen can be prescribed. 136.110. 55. 25. educational remediation specialists. it often becomes necessary to adapt the learning environment.” During these years. and active reading comprehension. an IEP contract should be developed. 208. 24. vocabulary.81 Schools can implement academic accommodations and modiﬁcations to help students with dyslexia succeed. A multidisciplinary team consisting of educators. 55. 239. 14. The burden of proof is on the promoters of vision therapy to provide strong evidence to show that their testing methods are valid. ####Refs 1. 211. Remedial programs should include speciﬁc instruction in decoding. special service professionals. and comprehension. 276. controlled scientiﬁc studies to document the effectiveness of vision therapy. and semantics are taught. Because people with dyslexia have a persistent problem and continue to read slowly throughout their life.34 A child with suspected learning disabilities should be placed into remediation and be referred as early as possible for educational evaluation. 266. 215. and pediatric specialists in neurodevelopmental disabilities or developmental and behavioral pediatrics should be called on to diagnose and treat suspected learning disabilities in children. or physician should be seen by an ophthalmologist who has experience with the assessment and treatment of children. syllable instruction.Other than convergence-insufﬁciency treatment. and early phonologic awareness intervention programs in kindergarten through 2nd grade should be encouraged. 214. at great cost. 233–236. spelling. 60. controversial methods of treatment may give parents and teachers a false sense of security that a child’s reading difﬁculties are being addressed. morphology. and 278.113. 14.35 Practicereading aloud at home is essential.
Immediate Past Chairperson Sharon S. MPH
*****Refs 1. Troia. Adams.***** The prognosis depends on the severity of the disability.org
. AAP Section on Ophthalmology Walter M. Lueder. MD Gregg T. Children diagnosed with learning disabilities should receive appropriate support and individualized evidencebased educational interventions combined with psychological. MSEd – Family Voices Max Wiznitzer. psychological. MD Susan E. MD. MPH Susan E. MPH Douglas McNeal. Karr. MD. psychologists. Lehman. behavioral/perceptual vision therapy. training glasses. Bradford. MD. MD
Paul H. PhD – Maternal and Child Health Bureau Nora Wells. 60. Ruben. Scientiﬁc evidence does not support the efﬁcacy of eye exercises. because the beneﬁcial effects of early identiﬁcation and intervention are apparent in many studies.106 Because vision therapy is not evidence based. Turchi. Murphy. MPH – Centers for Disease Control and Prevention Bonnie Strickland. Early intervention with intense.
Underachievement is not synonymous with speciﬁc learning disability. 81.112. AAP Section on Ophthalmology
SECTION ON OPHTHALMOLOGY EXECUTIVE COMMITTEE. the public must learn to carefully evaluate the information that they receive in the face of aggressive promotion. Dyslexia is a primary receptive language-based reading disorder secondary to a neurobiological deﬁcit in the processing of the sound structure of language called a phonemic deﬁcit that makes it difﬁcult to use
PEDIATRICS Volume 127. amount. Handler. MD – American Academy of Ophthalmology Council
Jennifer G. Visual problems do not cause dyslexia. 63– 65. and other problems. 30–35.279 Learning disabilities arise from neurologic differences in brain structure and function that affect the brain’s ability to store. Chairperson Richard C. and the appropriateness. interdisciplinary management strategies are the keys to helping children with dyslexia. 2010 –2011
James B. psychological. Ellis.167 In addition. MD. 24. MD – American Academy of Ophthalmology and Learning Disabilities Subcommittee. Morse.24–26 Missing these problems could cause long-term consequences from assigning these patients to incorrect treatment categories. and timing of the intervention. Wiley. CO – American Association of Certiﬁed Orthoptists Christie L. process.239. experiential and/or instructional deﬁcits. Arnoldi. Learning Disabilities Subcommittee. Reading difﬁculties constitute a diverse group of problems that include dyslexia and secondary forms of reading difﬁculties caused by visual or hearing disorders. educational. MD Gregory S. MD Daniel J. Number 3. MD Miriam A. March 2011
the alphabetic code. MD – Chairperson. MD. MD – American Academy of Ophthalmology Michael R. MD. MD Geoffrey E. Recommendations for multidisciplinary evaluation and management must be based on evidence of proven effectiveness demonstrated by objective scientiﬁc methodology. MD Robert T. Burke. and 106. 55. MD
Kyle A. the primary care pediatrician and ophthalmologist should discuss the lack of proven efﬁcacy of vision therapy and other alternative treatments with the parents. 25. or special tinted ﬁlters or lenses in improving the long-term educational performance in these complex pediatric neurocognitive conditions. Fierson. and/or medical diagnostic assessments. MPH Sandra L. and visual treatments as needed.270. it cannot be advocated. MD Renee M. Council on Children With Disabilities Executive Committee
Carolyn Bridgemohan. MD Kenneth W. there currently are no simple remedies. The consensus of educators. Jr. intensity. including dyslexia. Redmond.interdys. MD – American Association for Pediatric Ophthalmology and Strabismus George S.106. and medical specialists is that children who exhibit signs of learning disabilities should be referred as early as possible for educational. Norwood Jr. Levy.
OTHER RESOURCES International Dyslexia Association: www. MD.276 It is important that any therapy for learning disabilities be scientiﬁcally established to be valid before it can be recommended for treatment. treatment should be directed at this etiology. the speciﬁc patterns of strengths and weaknesses. Early recognition and individualized.14. or other appropriate evaluation or services. MD. or communicate information. Because of our rudimentary knowledge of learning disabilities. MD Sebastian J.
Sheryl M. Finally. Granet. MD – Section on Developmental and Behavioral Pediatrics Georgina Peacock. neuropsychological. MD – Immediate Past Chairperson. Blocker. medical. Riefe. MEd
COUNCIL ON CHILDREN WITH DISABILITIES EXECUTIVE COMMITTEE. Lipkin. Kalichman. Friedman. Because dyslexia is a language-based disorder. Chairperson David B.FROM THE AMERICAN ACADEMY OF PEDIATRICS
ties and reinforce the need for additional medical. Chairperson-Elect Richard J. 2010 –2011
Nancy A. explicit instruction is critical for helping students ameliorate the lifelong consequences of poor reading. MD – Section on Neurology
Stephanie Mucha Skipper. 14. Liptak. intellectual disability.
14(5): 581– 615 8. Cohen SA. Washington.org Interdisciplinary Council on Developmental and Learning Disorders: www.dys-add. 2010 Granet DB. Dyslexia. The science of reading and dyslexia. ldonline. Pennington BF. 1959 14.2(10):498 –506 10. 2006. NIH Publication 00-4769.
34. Washington. 1970. Word blindness in school children. Gomi CF. New York. Cohen SA. Pediatrics. National Joint Committee for Learning Disabilities.291(16): 2007–2012
FROM THE AMERICAN ACADEMY OF PEDIATRICS
. National Institutes of Health. 2001.
29. Available at: www. London. 2010 2.schwablearning. Department of Health and Human Services. The neurobiology of reading and dyslexia. Shaywitz BA. Castro EF. 2004. Pediatrics. Arch Neurol Psychiatr.National Center for Learning Disabilities: www. Copenhagen. K. Available at: www.net/?id 278. 2003 Torgesen JK.familyvoices. 2000. 1996. Accessed June 17. Accessed June 17.org/images/stories/ OnCapitolHill/PolicyRelatedPublications/ stateoﬂd/StateofLD2009-ﬁnal.
32.7(3): 158 –166 Council on Scientiﬁc Affairs. Prevalence and assessment of attentiondeﬁcit/hyperactivity disorder in primary care settings. Learning disabilities issues and deﬁnitions.45(1):2– 40 15.2(1871):1378 6. Overcoming Dyslexia: A New and Complete Science-Based Program for Overcoming Reading Problems at Any Level.html Family Voices: www. Fletcher JM. Availablei at: www.nichd. Kussmaul A. 1983. Accessed June 17. DC: US Government Printing Ofﬁce. Scanlon DM. 2010 3.ncld. New York.pediatrics.org/FAQ. Freeman WS.326(3):145–150 22. Stillman BW. JAMA. NY: Knopf. Available at: www. Shaywitz BA. Lewis & Co.
Text Revision. 1877:770 –778 4. A word deafness and word blindness. Accessed June 17. Makuch R. 1970. Available at: www.htm. Snowling MJ. 1936 17. Available at: www. Sci Am.org/ article/6339.org
13. J Child Psychol Psychiatry. Berlin R. Hinshelwood J. org Children and Adults With Attention Deﬁcit/Hyperactivity Disorder: www. Accessed June 17. NY: Sachett & Wilhelms. Birch HG. Escobar MD.pdf. Psychiatric comorbidity in children and adolescents with reading disability. A neurological explanation of the reading disability.
24. Speciﬁc reading disability (dyslexia): what have we learned in the past four decades? J Child Psychol Psychiatry. 2011 Rutter M. Available at: www. Studies in visual perception and reading in disadvantaged children. Hermann K. American Academy of Pediatrics. Available at: www. Morgan WP. chadd. Ann Dyslexia.
35. Taft LT. In: von Ziemssen H.107(3). Dyslexia. Evidence that dyslexia may represent the lower tail of a normal distribution of reading ability.33(S5): 18 –20 21.ncsall. 1887 7. Reading: do the eyes have it? Am Orthopt J. Report on learning disabilities research. Germany: Bergmann. 27.pacer. Learning disabilities: historical perspectives. Educ Rec. J Learn Disabil.org Learning Disabilities Online: www. Statement of Dr. Reid Lyon.56(1): 44 – 49 Lyon GR. Caspi A. 3(3):163–166 11. 20(suppl 12):58 – 68 9. National Reading Panel. Shaywitz SE. Mercer CD. Vellutino FR. 25. 2010 Lyon GR. Mattson PD. 45(2):302–314 12. “One jumped off the balance beam”: meta-analysis of perceptual-motor training.16(3):165–173
Great Schools Inc/Schwab Learning: www.41(8):1039 –1048 20. Clinical practice guideline: diagnosis and evaluation of the child with attention-deﬁcit/hyperactivity disorder. J Learn Disabil. 338(5):307–312 Shaywitz SE. J Learn Disabil.com REFERENCES
30. A case of congenital word blindness.com/ ReidLyonJeffords. Orton ST. Gillingham A. Hallahan DP.org/cgi/ content/full/107/3/e43 18. 2000.interdys. [in German]. 1998. N Engl J Med. J AAPOS. England: H. Some considerations for evaluating the Doman-Delacto “patterning” method. 1989. 1969.ncsall. Available at: www.org Parental Information and Resource Centers: www. Congenital Word-Blindness.ncld. Remedial Work for Reading. Dyslexia. A special kind of blindness (Dyslexia). Frequently asked questions about dyslexia.6(1):54 –76 Shaywitz SE.53(1): 1–14 International Dyslexia Association. NY: William Wood.pdf. Cyclopaedia of the Practice of Medicine.gov/programs/pirc/ index.
33. 31. Committee on Quality Improvement. 2010 Lyon GR.org/resources/ldsummit/ hallahan. Cohen HJ. Pediatrics. Denmark: Munksgaard. 2010 Shaywitz SE. Diagnostic and Statistical Manual of Mental Disorders.Spring/Summer.
26. Br Med J. Cause versus treatment in reading achievement. Shaywitz BA. and Penmanship. Am Educ. Orton ST. Reading Disability: A Medical Study of Word-Blindness and Related Handicaps. Kavale K. 1987.261(15):2236 –2239 Lyon GR. ASHA Suppl. 2000. G. Ltd. 2003. New York. eds. Accessed June 17.ed. 1925.gov/publications/nrp/upload/ smallbook_pdf. 1896. 1998. 1992. National Institute of Child Health and Human Development. Future Child. Shaywitz SE. Subcommittee on Attention-Deﬁcit/Hyperactivity Disorder. Perrin JM. et al.pdf. nih. 2010 23.256(3): 34 – 41 16.
36. Spelling. Teaching Children to Read: An Evidence-Based Assessment of the Scientiﬁc Research Literature on Reading and Its Implications for Reading Instruction. Vellutino FR. Wiesbaden. 1917 5. 1991. 4th ed.nrcld. A deﬁnition of dyslexia. The state of learning disabilities. American Psychiatric Association Task Force on DSM-IV.pdf.
28. McCreery JAT. Accessed February 7.pdf.org
National Center for the Study of Adult Learning and Literacy: www. Brown RT. Fergusson D.ldonline. N Engl J Med. Sex differences in developmental reading disability: new ﬁndings from 4 epidemiological studies.allkindsofminds. et al. icdl. Fletcher JM. DC: American Psychiatric Association. 2000 Shaywitz SE. Shaywitz BA. Catch them before they fail: identiﬁcation and assessment to prevent reading failure in young children.aft. 2004.org All Kinds of Minds: www. Accessed June 17. National Center for Learning Disabilities.net PACER Center: www.105(5):1158 –1170 19. Learning disabilities. 2003. JAMA. 1939. Willcutt EG.
Flynn JM. 1989. Neural systems affected in developmental dyslexia revealed by functional neuroimaging. 2006. Available at: www. Biol Psychiatry.75(pt 3):329 –348 46. Ment Retard Dev Disabil Res Rev. Raichle ME. 2003. CA: Academic Press. 2004. March 2011
. eds. DC: Thomas B. Washington. Shaywitz SE. 2009. Fox PT.19(10):759 –765 66. In: Wong BYL. Preventing Reading Difﬁculties in Young Children. 1994. Stanford.275(5): 98 –104 40. Bitan T. Shaywitz BA. Cracking the code. 2010 62.425(6956):340 –342 57. 1998. McCrory EJ. Fletcher JM. Moats LC. 1990.org/aboutld/ teachers/teaching_reading/not_natural. Mechelli A. 1999. et al. Positron emission tomographic studies of the cortical anatomy of single-word processing. et al. Rahbar MH. 1998 59. Blachman BA. In: Finn CE Jr. et al. vi
52. Eden GF. Attention deﬁcit disorder and learning disability: United States. MD: York Press. In: Masland RL. Swank LK.39(3): 252–269 71. 2000. ed. Psychol Sch. Washington. 2005. Murphy G. The “double deﬁcit hypothesis” for the developmental dyslexias.org/pdfs/ teachers/rocketscience0304. 2011. precise timing mechanisms. Interventions aimed at improving reading success: an evidence-based approach. 1998. and writing disabilities in the middle grades. 34(6):479 – 492 80. Parkton. Reading: a research-based approach. 1990. 2005. Theoretical links among naming speed. and cognitive mechanisms. Arch Neurol. Learning About Learning Disabilities. Prevalence of reading disability in boys and girls: results of the Connecticut Longitudinal Study. Shaywitz SE Rethinking learning disabilities. Development of left occipitotemporal systems for skilled reading in children af-
PEDIATRICS Volume 127. Bradley L. Leavell JA. Price CJ. Novey ES. Pugh KR. Frith U. Zefﬁro TA. Neurobiological studies of reading and reading disability. Neuroanatomic differences between dyslexic and normal readers on magnetic resonance imaging scans. 2003. Speciﬁc developmental disorders: the language-learning continuum. Fletcher JM. 1999. et al.47(10): 1041–1050 74. Pediatr Rev. Fletcher JM. CA: Hoover Institution Press. Cao F. 2006.104(6):1351–1359 48. Snow CE. Pastor PN. Lerner JW. 1988:143–162 63. Pugh KR. Fulbright RK. Sci Am. Pediatr Clin North Am.28(3):326 –331 64.54(3):507–523. Proc Natl Acad Sci USA. Accessed June 17. Moats LC. Hokanson CR Jr. Escobar MD. Shaywitz BA. 1991. 1988. Semrud-Clikeman M. 1997–98. J Educ Psychol. 21(2):279 –282 76. Dev Neuropsychol. In: Wong BYL. Rethinking Special Education for a New Century. Reuben CA.325(5938):280 –283 54. Bowers PG. Schatschneider C. J Commun Disord. Shaywitz SE. Holahan JM. Brain morphology in developmental dyslexia and attention deficit disorder/hyperactivity. Continuity between childhood dyslexia and adult reading. Principal Leadersh.21(9):571–580 51.FROM THE AMERICAN ACADEMY OF PEDIATRICS
37. 1996. Duara R. Eliopulos D.54(1):25–33 49. Alarcon M. Developmental lag versus deficit models of reading disability: a longitudinal individual growth curve analysis. Kushch A. Deﬁcient orthographic and phonological representations in children with dyslexia revealed by brain activation patterns. Accessed January 26. Mencl WE. Gross-Glenn K. asp. Joyce MT. Br J Psychol. Teaching Reading Is Rocket Science: What Expert Teachers of Reading Should Know and Be Able to Do. J Child Neurol. Arch Neurol. Wolf M. Hynd GW. Mann VA. Foorman BR.31(1):66 –71 38. Breier JI. ed. Dyslexia: a new synergy between education and cognitive neuroscience. 1998:367–390 73. 2002. ed. Gabrieli JD. 1999. Pediatrics. 1984. In press 43. Jenner AR. neurological. et al. Educational interventions in learning disabilities. Francis DJ. Learning disabilities and school failure. 1996. Ment Retard Dev Disabil Res Rev. J Learn Disabil. 1998:49 –90 56. Pugh KR. Persistence of dyslexia: the Connecticut Longitudinal Study at adolescence. Mencl WE. JAMA. Shaywitz SE. J Am Acad Child Adolesc Psychiatry. 2000. Shaywitz SE. 1995. Juel C. DC: American Federation of Teachers. 1993. LDA Newsbriefs. Jenner AR. vi 58. Shaywitz BA. More than words: a common neural basis for reading and naming deﬁcits in developmental dyslexia? Brain. Grifﬁn P. Do different components of working memory underlie different subgroups of reading disabilities? J Learn Disabil. eds. Prevalence of reading failure in boys compared with girls. Pugh KR. Mintun M. 1996.7(2):189 –216 68. Language problems: a key to early reading problems. Booth JR. Fordham Foundation and the Progressive Policy Institute. 2011 65. Disruption of posterior brain systems for reading in children with developmental dyslexia. Using our current understanding of dyslexia to support early identiﬁcation and intervention.264(8): 998 –1002 39. et al. Dyslexia: lost for words. Genetics of speciﬁc reading disability. 2003. San Diego. Swanson HL. DC: National Academy Press.38(4). Sáez L.ldanatl. Burman DD.91(3):1–24 70. et al. 2007.88(1):3–17 45. In: Evers WM. Reading. Functional neuroimaging studies of reading and reading disability (developmental dyslexia).6(3):207–213 79. DeFries JC. 48(4):410 – 416 75. Fletcher JM. Nature. Rhyme recognition and reading and spelling in young children. Chou TL. Rotherham AJ. Petersen SE. 1998:163–202 60. Science.11(3):629 – 654 41. Read Writ. Number 3. Posner MI.128(pt 2): 261–267 67. 2003.2(1):39 – 47 42.5(1):69 – 85 69. Nature. Lorys AR. (206):1–12 55. Shaywitz BA. Masland MW. J Child Psychol Psychiatry.November:29 –35 53. Does a visual-orthographic deficit contribute to reading disability? Ann Dyslexia. and orthographic skill in dyslexia. Available at: www. Neuron.55(1):28 –52 72. San Diego. Fletcher JM. Tracing symbol naming speed’s
unique contributions to reading disabilities over time. Dyslexia. Developmental dyslexia. Shaywitz SE. Rimrodt SL. 2001:259 –287 44. 1999.95(5):2636 –2641 50.8(1):89 –112. CA: Academic Press. Lyon GR. 331(6157):585–589 78. What’s Gone Wrong in America’s Classrooms. Preschool Prevention of Reading Failure.24(2–3):613– 639 61. Burns MS. Grizzle KL. Child Adolesc Psychiatr Clin N Am. eds.aft. Vital Health Stat 10. Shaywitz BA. 1999. Why reading is not a natural process.pdf. Wolf M. Badian NA. Washington. Torgesen JK. Howard CB.52(2): 101–110 47. Bowers PG. spelling. Neural systems for compensation and persistence: young adult outcome of childhood reading disability. 2002. Shaywitz SE. et al. Biol Psychiatry. 1988. 2001. Scarborough HS.47(8):919 –926 77. Dev Psychopathol. Functional disruption in the organization of the brain for reading in dyslexia. J Educ Psychol. Learning About Learning Disabilities. Toward an integrated understanding of dyslexia: genetic. Lipkin PH. Bowers PG. 2nd ed. Stanford University. Read Writ. Retention and nonretention of at-risk readers in ﬁrst grade and their subsequent reading achievement. Pennington BF. Shaywitz SE. Lyon GR.
Section on Ophthalmology.128(pt 10): 2453–2461 Temple E. Multisensory programs in the public schools: a brighter future for LD children.
106. American Association of Certiﬁed Orthoptists. Pediatric Ophthalmology and Strabismus.73(6):824 – 829 Stifter E.39(1):247–267 American Academy of Pediatrics. 2001. children. Critical conceptual and methodological considerations in reading intervention research. Accessed June 17.81. 18(2):222–233 Galaburda AM. 1999.
112. Accessed June 17. Developmental dyslexia (speciﬁc reading difﬁculty). Fitch RH. Available at: http://ldonline. Accessed June 17.gov/about/ofﬁces/list/ocr/ 504faq.
101. Newman RS. Young CL. Parenting corner Q&A: learning disabilities. 2010 US Department of Education. Available at: www.aao. Burggasser G. 1988. Ann Neurol.119(6):1218 –1223 US Access Board. 2005.66:127–137 Galaburda AM.313(7065):1096 –1097 National Joint Committee on Learning Disabilities.55(9):926 –933 Shaywitz SE. Learn Disabil Res Pract.
102. 2010 US Department of Education. Kowal LW.
92. 1984. Available at: www.org/ ewebeditpro5/upload/IDA_Position_ Statement_Dyslexia_Treatment_ Programs_template(2). Pediatrics.
Health and Human Development’s contribution to reading.
98. 2010 Shaywitz SE. A guide to disability rights laws. 2010 Martin FJ. Brain abnormalities underlying altered activation in dyslexia: a voxel based morphometry study. Mock D. Pediatrics. Ofﬁce for Civil Rights. evidence.12(2):299 –307 Temple E.aspx. Nat Neurosci. 2011 US Department of Justice. Ann Dyslexia. Pediatrics.ldonline. Preferred Practice Pattern Guidelines: Pediatric Eye Evaluations.
99. 1979. Available at: http:// one.usdoj.
97. Pediatric Ophthalmology/Strabismus Panel. aspx?cid 761ac199-5cfe-42f4-b40b33f9d5f0d364. Hoyt C. San Francisco. Pediatrics. Learning disabilities and young children: identiﬁcation and intervention. 1986.111(4 pt 1):902–907 American Academy of Ophthalmology. htm. Morgan PL.ed. Rosen GD. 2003. 6(2):94 –100 Galaburda AM.html.
113. Brain. Werner DB. 2005 American Academy of Pediatrics.htm. 2010 Cartwright JD. BMJ. 1996. Dyslexia: a hundred years on. Shaywitz BA.
100. Avoiding the Devastating Downward Spiral.104(1 pt 1): 124 –127 American Academy of Pediatrics. The ADA Amendments Act of 2008. Pediatr Clin North Am.pdf. The ophthalmologist and learning disabilities. Council on Children With Disabilities. 2005.18(3):157–171 National Joint Committee on Learning Disabilities. Shaywitz BA. 2011 Olitsky SE. Focal Points Clinician’s Corner. Geschwind N.org/newspubs/
FROM THE AMERICAN ACADEMY OF PEDIATRICS
. LoTurco J. CA: American Academy of Ophthalmology.
110. Salidis J. Promoting early literacy in pediatric practice: twenty years of reach out and read. Building the legacy: IDEA 2004. Demonet JF. Biol Psychiatry. 2007. Proc Natl Acad Sci USA. eds. Lyon GR. Res Publ Assoc Res Nerv Ment Dis.aft. Kemper TL. Disrupted neural responses to phonological and orthographic processing in dyslexic children: an fMRI study.
104. et al. Accessed June 17. 2003.aap. Long-term prediction of achievement and attitudes in mathematics and reading. The pathogenesis of childhood dyslexia.109(3): 519 –521 Ogden S.org/article/ 11511?theme print. In: Taylor D. Moats LC.
88. Ann Neurol.9(10):1213–1217 Snowling MJ. Available at: www. Rosen GD. American Academy of Ophthalmology. et al. 34(3):548 –558 Lyon GR. 1997. Civil Rights Division. Pediatrics. American Association for Pediatric Ophthalmology and Strabismus. Management of dyslexia.57(11):1301–1309 Silani G. Deutsch GK. Hindman S. Developmental dyslexia: four consecutive patients with cortical anomalies. From genes to behavior in developmental dyslexia. Evidence-based assessment of learning disabilities in children and adolescents.cfm. Neuroreport. 2004:714 –721 Metzger RL. 2010 Hertle RW. and young adults by pediatricians. Ltd. Protecting students with disabilities: frequently asked questions about Section 504 and the education of children with disabilities.
94. 2010 Zuckerman B. Child Dev. Reading disorders in children. 2007. Ramus F.
84. J Clin Child Adolesc Psychol. CA: American Academy of Ophthalmology. viii Shaywitz SE. Use of visual training for reading disabilities: a review. American Academy of Pediatrics.
114. 34(3):506 –522 Kazdin AE.
89. Nelson LB. 2009. Eye examination in infants. 2005. Accessed June 17. 1985. The pediatrician’s role in development and implementation of an Individual Education Plan (IEP) and/or an Individual Family Service Plan (IFSP).100(5):2860 –2865 Galaburda AM. IDA position statement: dyslexia treatment programs. et al. Available at: http:// idea. Morris RD. The Evidence that Early Intervention Prevents Reading Failure. J Clin Child Adolesc Psychol. 91. Accessed February 7. 2001.
87. Available at: www. 2006. Accessed June 17. Science informing policy: the National Institute of Child
107.gov/about/laws/ada-amendments. Accessed June 17. 2007.
111. Shaywitz BA.
109. Pediatr Clin North Am. 2010 Fletcher JM. 2004. Frith U. Accessed June 17. 2010 Fuchs D. Complementary Therapy Assessment: Vision Therapy for Learning Disabilities.org/publiced/BR_ LearningDisabilities.
85. Cytoarchitectonic abnormalities in developmental dyslexia: a case study. 3rd ed.
periodicals/ae/fall2004/torgesen. its rationale.interdys. Gruen JR. Available at: www. J Learn Disabil. Accessed June 17. Aboitiz F. MO: Saunders. Available at: www. 1989. and underlying neurobiology. Hirmann E. 57(3):646 – 659 Torgesen JK.
ter a phonologically-based intervention.124(6): 1660 –1665 Stevenson HW. 50(1):213–224 American Academy of Ophthalmology. Responsiveness-to-intervention: deﬁnitions.ed. Provision of educationally related services for children and adolescents with chronic diseases and disabling conditions. Biol Psychiatry. Poldrack RA.org/CE/PracticeGuidelines/ Therapy. Yeates KO. Accessed February 7.
103. Poldrack RA. Available at: www.
86. Neural deﬁcits in children with dyslexia ameliorated by behavioral remediation: evidence from functional MRI. and implications for the learning disabilities construct.accessboard.
93. 2003. Complementary Therapy Task Force. 2005.org/ article/Responsiveness_to_Intervention_ and_Learning_Disabilities?theme print. Pediatrics. Available at: http://one. Committee on Practice and Ambulatory Medicine. San Francisco. Dyslexia (speciﬁc reading disability). Responsiveness to intervention and learning disabilities. 2002. htm.
105. Committee on Children With Disabilities. Evidence-based assessment for children and adolescents: issues in measurement development and clinical application.org/CE/ PracticeGuidelines/PPP_Content.30(6):578 –588 International Dyslexia Association.
116.aao. Francis DJ.gov/crt/ada/cguide.
108. Turner SD.54(3):609 – 623. St Louis. 2003. Sherman GF.
1982. J Pediatr Ophthalmol Strabismus.
146.49:26 –30 Chrousos GA.60(6):927–934 Brown B. 149. Available at: www. The use of selected perceptual tests in differentiating between normal and learning disabled children. 1998.44(2):113–121 Ip JM. 1975. 44(4):637– 648 Judge J. Some characteristics of readers’ eye movements.89(10):1324 –1329 McConkie GW. Eye movements and the perceptual span in beginning and skilled readers. Eye movements of preschool children. Convergence insufﬁciency.
130.84(2):110 –114 Costenbader FD. Solan H. Cacho P.56(1):18 –22 Cassin B. Psychol Bull. Wimmer H.
159. Am J Optom Physiol Opt. 1991. Yingling CD. Collins DW. 2006. Characteristics and diagnosis of convergence insufﬁciency. Robaei D. Hyman L. Available at: http://one. Am Orthoptic J. Visual at-
131. Cogn Neuropsychol. Giordani B. Correlation between
147. Perhaps correlational but not causal: no effect of dyslexic readers’ magnocellular system on their eye movements during reading.
142. Learning disabilities: update comment on the visual system.85(3):618 – 660 Rayner K. Atzmon D. Reading disability: do the eyes have it? Pediatrics.
121. Lueth BD. Zubrick S. 1975.25:38 – 45 Robinson ME. Caravolas M. Azoulay E. Visual function and academic performance.
143. Convergence Insufﬁciency and Reading Study (CIRS) Group. Br J Ophthalmol. Schwartz LB.17(6): 536 –539 Lara F.
138.15(3): 281–286 Larsen SC. Raney GE.70(1):3–13 Wright JD Jr. Accommodation deﬁciency in healthy young individuals. 2006. Accessed June 17. Accessed February 7. Marcus M.9(2):85–90 Larsen SC. J Pediatr Ophthalmol Strabismus. VergilinoPerez D. 59(2):423– 434 Blika S.org/CE/ PracticeGuidelines/PPP_Content.
reading skills and different measurements of convergence amplitude. Preferred Practice Pattern Guidelines: Amblyopia. June 19 –22. Am J Optom Physiol Opt. 1987.
156. Acta Ophthalmol (Copenh). Megias R. 1987.
A. 1987.and poorreading children.
144. Management of dyslexia and related learning disabilities. Preferred Practice Pattern Guidelines: Esotropia and Exotropia. 2010 Jenkins RH. J Learn Disabil. Jacobs AM. Vellutino FR.
134. 1979. Am J Ophthalmol. Lamont A.
154. Vision Res. Vision Res. Number 3. Ophthalmic Physiol Opt. Eye movements in reading and information processing.
152. Dev Med Child Neurol. Mitchell P. Am Orthopt J. Lennerstrand G. CA: American Academy of Ophthalmology. and Visual Analysis in Reading—Proceedings of the 7th International Rodin Remediation Conference at the Wenner-Gren Center. 2011 Donahue SP.
133. The improved accommo-
PEDIATRICS Volume 127. Reading disappearing text: cognitive control of eye movements. 1989:369 –381 Rayner K. Parks MM. Dev Med Child Neurol.
157. Knox PC.htm.
151. 1982. Monocular and binocular reading performance in children with microstrabismic amblyopia. Memory Functions. Visuo-motor skills and reading ability: a longitudinal study. Am Orthoptic J. Simon JW.25(2):117–121 Létourneau JE. Kosmorsky G.24(3):260 –278 Rayner K. Avni I. Garcia A.
145.FROM THE AMERICAN ACADEMY OF PEDIATRICS
118. Lederman R.20(7):415– 421 Lennerstrand G.aao.22(5):1188 –1200 Rayner K.49:7–11 Stidwill D.49:23–25 Hodgetts DJ. J Exp Psychol Hum Percept Perform. Accessed February 8. Liversedge SP. 1978. 139. Liversedge SP. 1986. In: von Euler C.
tention in adults with developmental dyslexia: evidence from manual reaction time and saccade latency. 2011 American Academy of Ophthalmology. Visual training and reading. Visual complaints from healthy children.
124. 1973. Pediatric Ophthalmology/Strabismus Panel. The relationship between convergence insufﬁciency and ADHD. Sibila TA.
128. Segal O. Optom Vis Sci.
122. Reading twisted text: implications for the role of saccades. Ygge J. Dyslexia: ophthalmological aspects 1991. 1984.
141. MillerScholte A. Nagy J. Prescribing spectacles in children: a pediatric ophthalmologist’s approach. Am J Ophthalmol. Science.29(4):477– 485 Beauchamp GR. O’Neill JF.
126. 1999. Percept Mot Skills.
119.196(4285):77–79 Helveston EM. 2001.13(4):163–168 Morad Y. Weber JC. Sowell V. Galin D.
140. Epidemiology of strabismus.aao. eds. 1977. Normal reading despite limited eye movements. Linguistic Processes. Rochtchina E. Wick BC. Optom Vis Sci. Lapierre N.
120. Sereno SC. 2007. CA: American Academy of Ophthalmology. 1996.
150. 2007. 1983.
123. 14(4):385–388 Rayner K. Hussein M.aspx?cid 930d01f2-740b433e-a973-cf68565bd27b. General binocular disorders: prevalence in a clinic population. 2007.21(1):70 –74 Rouse MW. Problems with accommodation. 2005. Martins AJ. NY: Stockton Press.
125. Haegerstrom-Portnoy G. Am Orthoptic J.
132.com/oph/ topic553. 1999.
127. A detailed study of sequential saccadic eye movements for normal.9(3): 281–291 Morrison FJ.
160. Tracking eye movements are normal in dyslexic children. Hammill DD. 60(5):376 –383 Hall PS.
153. White SJ. 1992. Acta Ophthalmol (Copenh). 215(4535):997–999 Hoyt CS. 2002. Science.41(2):211–236 Polatajko HJ. Available at: http://one. New York. Scanlon DM. Strabismus and learning disabilities. Eye movements when reading disappearing text: the importance of the word to the right of ﬁxation. March 2011
. Rodgers D. 1984. Miller K. Visual-ocular control of normal and learning-disabled children. 2(3):182–183 Frank JW. J AAPOS. 1985. Neuropsychologia.25(4):176 –179 Bartiss MJ. Reading disability: an information-processing analysis.
148. Gomi CF. J Exp Child Psychol. Kronbichler M. 129. Zola D. Strabismus. Eye movement control in reading: a comparison of two types of models.org/CE/PracticeGuidelines/ PPP_Content. 2003. Ventura R. 1998. Radner W. Psychol Sci. Boger WP 3rd. 1988. 1988. White SJ. Stockholm and Uppsala University.27(1):45– 60 Kowler E.75(2):88 –96 Granet DB. The relationship between convergence insufﬁciency and school achievement. Ophthalmological ﬁndings in pupils of a primary school with particular reference to reading difﬁculties. Brain and Reading: Structural and Functional Anomalies in Developmental Dyslexia With Special Reference to Hemispheric Interactions. aspx?cid 89921a42-f4b1-47e4-a5ef6cbbce4d0197.99(3):346 –355 Levine MD. 1976. Frequency of convergence insufﬁciency in optometry clinic settings. 1999.
155. 1987. The relationship of selected visual-perceptual abilities to school learning. Surv Ophthalmol. 1999.34(6): 1439 –1446 Black JL.46(3): 310 –323 Kowler E. 2006. San Francisco. De Roach JN.73(6):869 – 870 Hutzler F. 137. The relationship between ocular functions and reading achievement.142(3):495– 497 American Academy of Ophthalmology. Anton S. J Learn Disabil. 2007. Ophthalmic Physiol Opt. 1997.28(1):17–19 Helveston EM. Lundberg I.emedicine. Pediatric Ophthalmology/Strabismus Panel. J Spec Educ. et al. Curr Eye Res. San Francisco. Prevalence of eye disorders in young children with eyestrain complaints. Herron J. Pediatr Clin North Am.
Drislane FW. PLoS Med. Controversial therapies. Clin Exp Optom. Breitmeyer BG.42(2):142–157 Skottun BC. 2010 171. 1999. J Learn Disabil. 2005 169. Hufﬁne CW. Learning Disabilities [patient-education brochure]. Am Orthopt J. Randomized clinical trial of treatments for symptomatic convergence insufﬁciency in children. 2006. 1998.89(4): 241–245 Skottun BC. Magnocellular reading and dyslexia. Accessed June 17. and psychophysical magnocellular thresholds in glaucoma. 2005. 1991. html. Dyslexia.
204. J Learn Disabil. The magnocellular theory of developmental dyslexia. Scotopic sensitivity syndrome.
206. Accessed June 17.readingrockets. Zapart S. Brain Lang.
196. 125(pt 10):2272–2285 Conlon E.117(2):287–293 Skottun BC. 2001. 1997. 2005.unc. Anaheim. 2004. 2010.126(10):1336 –1349 164. Available at: www.126(10):1455–1456 165. J Learn Disabil.
202. Walsh V. 2004. J Child Neurol. 49:12–16 163. N Engl J Med. Does popularity lead to unreliability in scientiﬁc research? Available at: www. Introduction to Evidence-Based Medicine.110(7): 933–934 Stein JF.23(10): 613– 620 Helveston EM. On the prevalence of magnocellular deﬁcits in the visual system of non-dyslexic individuals. Haynes RB. 312(7023):71–72 170. CA: American Academy of Ophthalmology. Skoyles JR.61(2):225–226 161. Is coherent motion an appropriate test for magnocellular sensitivity? Brain Cogn. Rosen GD. NY: Academic Press. 1990. and the ﬁrst amendment: what’s a profession to do? Am J Orthopsychiatry. Disabled readers suffer from visual and auditory impairments but not from a spe-
192. To see but not to read. Lovegrove W. 2010 173. dyslexia.83(7):486 – 498 Skoyles J. Turner L. 2002. Physiological and anatomical evidence for a magnocellular defect in developmental dyslexia.328(14):989 –996 Livingstone MS.
188.360(1):1–3 176. Proc Natl Acad Sci USA. 2000. Duke University Medical Center Library and University of North Carolina at Chapel Hill Health Science Library. San Francisco.
191. New York. Garzia RP. 4th ed. author reply 135–136 Skottun BC. Why most published research ﬁndings are false. Wren S. Attention. A randomized clinical trial of treatments for convergence insufﬁciency in children. Rosenberg WM.jsp?id 84. In: Rayner K. Ben-Yehudah G. 2005. Arch Ophthalmol. Hash T. 1993. A defective visual pathway in children with reading disability. Available at: www. Nass RD. 1983.40(1):111–127 Skottun BC. Skoyles JR.edu/Services/ Tutorials/EBM. and the line-motion illusion. Kushner BJ. Yellow ﬁlters. Dyslexia at the New York Times: (mis)understanding of parallel visual processing. 1993. Helveston EM.sciencebasedmedicine.
193. 2010 175. 1999. ed. 49:173–177 168. Visual training: current status in ophthalmology. Convergence Insufﬁciency Treatment Trial Study Group.108(9): 1232–1233 Silver LB. 1996. August 26 –30. 1999. Temporal processing in poor adult readers. 2006. American Academy of Ophthalmology.23(4):207–212 Worrall RS.
185. Communicating medical news: pitfalls of health care journalism. Treatment options for symptomatic convergence insufﬁciency. Cotter S. Clin Vis Sci. 2010 Kennedy SS.
200. 2006. control. optic atrophy. Vis Neurosci. Accessed June 17. Arch Ophthalmol. Sanders M. Brain. Skottun BC. Nat Rev Urol. Galaburda AM. Arch Ophthalmol. Banai K. Nelson P. 179.45(1):133–134. Baro JA.
186. Skoyles J.123(pt 1):164 –170 Iovino I. Brain.
ciﬁc magnocellular deﬁcit. 1990. Eye Movements in Reading: Perceptual and Language Processes.
180.88(18):7943–7947 Stein J.7(1): 12–36 Lehmkuhle S.
research. Arch Ophthalmol. ethics. Optom Vis Sci.10(suppl 1):S96 –S100 Silver L. Visual evoked potentials in dyslexics and normals: failure to ﬁnd a difference in transient or steady-state responses. 1983: 3–31 Stein J. Ten myths about learning to read. persistence and enhancement in visual exploration and reading. Martin F. Accessed June 17. Clinical trials: trial registration cannot alone transform scientiﬁc conduct. BMJ.61(2):172–180 Vaegan.21(1):63– 68 Skottun BC. Defective visual pathway in reading-disabled children. and reading.
178. Eye-related quackery. The magnocellular deﬁcit theory of dyslexia: the evidence from contrast sensitivity.org/?p 553//more-553. The treatment of convergence insufﬁciency. Vision Res. Richardson AJ. Parke LA.
205. Skoyles JR. Ahissar M.org/ article/351. 2007. Mitchell GL. Moja L. 2004.quackwatch. 1990. Burton L. N Engl J Med. Trans Am Acad Ophthalmol Otolaryngol. Detecting health fraud in the ﬁeld of learning disabilities.
201. Foorman BR.
194. Trends Neurosci. Nevyas J. 1957.dometer. Visual-evoked response. and dyslexia. Arch Ophthalmol. 2008.
182. Evidence based medicine: what it is and what it isn’t. Scheiman M. Conte MM. 2000.
203.20(4):147–152 Victor JD.123(1):14 –24 166. 2006. 183.7(1):7– 8 174.32(1):2–5 Skottun BC. The treatment of convergence insufﬁciency. 2010. Dentzer S. Accessed June 17. 2008. reading and dyslexia. Mercer J. Int J Neurosci. On the use of red stimuli to isolate magnocellular responses in psychophysical experiments: a perspective. Power.329(8):579 Amitay S. Richardson WS. Attention. 1991. CA
FROM THE AMERICAN ACADEMY OF PEDIATRICS
199. et al. 123(1):100 –101 162. Available at: www. Optom Vis Sci. the magnocellular theory of dyslexia. Vis Neurosci. 1993. Presented at: 91st annual convention of the American Psychological Association.20(6):791– 806 Irlen H. 2002.
184. An ophthalmologist’s approach to children with visual perception and learning differences. Colored overlays for visual perceptual deﬁcits in children with reading disability and attention deﬁcit/ hyperactivity disorder: are they differentially effective? J Clin Exp Neuropsychol. 2005. Ioannidis JPA. 1995. Sensory masking. 1992.83(11):843– 849 Skottun BC. and validity in 189.10(5):939 –946 May J. Parker RM.72(1):5–15 Worrall RS. Hollows FC. Arch Ophthalmol.88(1):79 – 82 Sadun AA. 2009.
195. Snake oil.mtsu. Gorski D. 177.hsl. Am Orthoptic J. 2(8):e124 172. 181. magnocellular responses.edu/ modules/articles/displayarticle. Pattern-elicited visual evoked potentials in good and poor readers. Petrunak JL. Barrett S. Koller HP. Fletcher JM. 6(2):131–136 Victor JD.140(5):903–910 167. Wallace DK. Fowler MS. com/01QuackeryRelatedTopics/eyequack. 2005. Sackett DL. In Breitmeyer B. Mohr W. Monocular occlusion can improve binocular control and reading in dyslexics. N Engl J Med. Am J Ophthalmol.
197. The possible relationship between visual deﬁcits and dyslexia: examination of a critical assumption. Neuropsychologia. Successful treatment of learning difﬁculties. Vision Res. Another claim of a treatment for learning disabilities: should you consider it? Available at: http://dyslexia. pattern electroretinogram. Gray JA.
1933. Parisi M. New York.
228. 1994. and their theoretical and practical implications. 1995. Dana JP.
250. Robinson G.28(4):240 –252 Lightstone A.
244. Jones LA. Interv School Clin.23(10):621– 626 212. and ﬁxation disparity in oculomotor problems. J Learn Disabil. J Learn Disabil. php?s inewsletters. 1990. Wilkins AJ. 55(11):744 –750 Walline JJ. Santa Ana. J Learn Disabil. 55(10):670 – 676 Sheedy JE.
248. and reading. Menacker SJ. Number 3.
231. Ophthalmic Physiol Opt. Smith DL. 1978. Maples WC. Grisham JD. Robinson GL. March 2011
.42(3):879 – 884 Solan HA.
245. Dyslexia and learning disabilities: an overview.
232. vergence. An appraisal of the Irlen technique of correcting reading disorders using tinted overlays and tinted lenses.19(4):279 –285 Cotton MM.23(10):604 – 612 215. Arch Ophthalmol.
lens wearers. Gole GA. Mutti DO. Grosser GS. Yellow ﬁlters can improve magnocellular function: motion sensitivity. 1039:283–293 Coyle B. Randomised controlled trial of the effect of coloured overlays on the rate of reading of
221. Evans KM. 65(11):893–904 Simons HD. Wilkins AJ. Ann N Y Acad Sci.
241. Zadnik K. Irlen International Newsletter. Introduction to Clinical Optometry.2(4):93 Flax N.19(4): 277–278 Rooney KJ. Optometry. Grifﬁn JR. O’Connor PD. Optom Vis Sci. Selznick R. Blaskey P. Saladin JJ. Physiologic exophoria in relation to age. Irlen Institute. Dibden SN.
247. et al. J Am Optom Assoc. 1990.com/index. Arch Ophthalmol. Scheiman M. Invest Ophthalmol Vis Sci. Do visual problems cause dyslexia? Ophthalmic Physiol Opt. J Am Optom Assoc. Irlen lenses: a critical appraisal. Rucker F. Hoyt CS 3rd. 1988 Hendrickson H. and vergence. J Learn Disabil. Rate of reading. 1998. Donatelle JR. Aust N Z J Ophthalmol.9(1): 104 –105 Freier BE. 2010 209.61(10): 789 –796 Romanchuk KG. Radcliffe J. Pickwell LD. Smith FK. Kohl P. convergence.8(1):9 –11 Eames TH. Am J Optom Physiol Opt.
238. 1993. Controversial therapies: a review and critique. Double-masked placebo-controlled trial of precision spectral ﬁlters in children who use coloured overlays. Percept Mot Skills.
224. Phoria. Ficarra A. 1997. J Behav Optom. heterophoria.75(8):605– 610 Scheiman M. 2000. Pearson CC. NJ: SLACK. 1991.
226. Sofo F. Australas J Spec Educ. 2nd ed. Eye movement efﬁciency in normal and reading disabled elementary school children: effects of varying luminance and wavelength. Sihra N. Ophthalmic Physiol Opt.
240.18(3):307–312 Wilkins AJ. Skefﬁngton syndrome case analysis. 1990. 26(3):134 –142 Jennings AJ. Myers A. Aust N Z J Ophthalmol. 2005. CMAJ.111(2):213–218 218.65(10):705–714 Woerz M. Spatiotemporal visual function in tinted
230.89(1):83–113 220. visual processing.23(10): 597– 603. The Light Barrier: Understanding the Mystery of Irlen Syndrome and LightBased Reading Difﬁculties.
234. Saladin JJ. J Am Optom Assoc. 1990. Saxerud MH. Accessed June 17. Available at: http://irlen. Optom Pract. Reading disabilities and the effects of colored ﬁlters. 1991. 1999. The effectiveness of Irlen ﬁlters for improving reading performance: a pilot study. CMAJ.153(4):397 Evans BJ. Wilkins AJ.3(3):13–20 Solan HA. Breton ME. Aust J Learn Disabil. Richman J. Ophthalmic Physiol Opt. Physiological exophoria.22(1):55– 60 Spafford CS. 1987.3(3): 267–272 Saladin JJ. Thorofare. Robinson GL. J Am Optom Assoc. Bex PJ. 1995.152(5):749 –750 Gole GA. A preface to the special series. Brown JA. J Learn Disabil. Brannan JR. Ciner EB. 1990. 2002 Solan HA. 18(1):3–14 217.58(7):578 –587 Sheedy JE. 1990.34(1):109 –120 Lopez R. Foreman PJ. Evans BJ. 1998. Tinted lenses and dyslexics: a controlled study.
227. Gassler PA.ca/contents/ view_article/207/?print false. accommodation.
people with speciﬁc learning difﬁculties. 2005. Contrast sensitivity differences between proﬁcient and disabled readers using colored lenses. et al.17(2): 137–141 Simmers AJ. 242.
233. Optom Vis Sci.
223. but their optimal chromaticities differ. reading strategies and causal mechanism. Ophthalmic Physiol Opt. A review of the use of Irlen (tinted) lenses. 1989. Vision anomalies and reading skill: a meta-analysis of the literature. J Learn Disabil. 1995. Wiederholt JL. Am J Optom Physiol Opt. 1978.30(2):214 –221 Stone R. Failure of blue-tinted lenses to change reading scores of dyslexic individuals. Behavioural optometry: a critical review.23(10):589 –596 213. Lightstone T. Irlen ﬁlters and learning disabilities. 1988. Both coloured overlays and coloured lenses can improve reading ﬂuency. 11(3):206 –217 216. Squillace SR. 1990. Breton ML. Bouldoukian J. Comparison of Irlen scotopic sensitivity syndrome test results to academic and visual performance data. 1994. Accessed June 17. Binocular anomalies and reading problems. CA: Optometric Extension Program Foundation. Association of symptoms with measures of oculomotor deﬁciencies. 1997.
246. Inc.A. Wilkins A. Do tinted lenses improve the reading performance of dyslexic children? A cohort study.) Tinted Lenses Study Group. Use of ﬁlters to treat visualperception problem creates adherents and sceptics. Am J Optom Physiol Opt.FROM THE AMERICAN ACADEMY OF PEDIATRICS
249.1(2): 67–78 Skefﬁngton AM.
237. J Learn Disabil. 1993. colour and contrast. 1994. Am J Optom Physiol Opt. 2002. Scotopic sensitivity/Irlen syndrome and the use of coloured ﬁlters: a long-term placebo controlled and masked study of reading achievement and perception of ability. Stein JF. NY: St Martin’s Press.
236. Fowler S. 1983.
239.72(10):627– 633 Ray NJ. Sheedy JE. SPELD (S. 2001. Available at: www.70(5):343– 347 Simons HD. Taylor M. 243. 1991. 1998. Gallaway M. J Behav Optom. 1999. Olsen G. Yolton RL. J Learn Disabil. 1990. Irlen lenses and reading difﬁculties. Coloured lenses and reading: a review of research into reading achievement. Increasing reading speed by using colours: issues concerning reliability and speciﬁcity. Development of phoria in children. 2001. Thoughts on Skefﬁngton. The effects of Irlen colored lenses on students’ speciﬁc reading skills and their perception of ability: a 12-month validity study. Scepticism about Irlen ﬁlters to treat learning disabilities. Evans BJ. 1977. Kendall L.69(7): 455– 464 Christenson GN. Drasdo N. Understanding and Managing Visual Deﬁcits: A Guide for Occupational Therapists. Conway RN. Solan HA.14(4):365–370 219. Tinted lenses and related therapies for learning disabilities: a review. Ophthalmic Physiol Opt. Perception. 2010 208. 2003 Croyle L. 1999.23(10): 624 – 626 210.23(10):588 211. Population study of ﬁxation disparity. Evans BJ. Chaban P.54(7): 474 – 478
PEDIATRICS Volume 127. Test-retest reliability of colored ﬁlter testing. 620 214.
Borsting EJ. 7(1):6 –11 262. Burley CD. Optom Vis Sci. Pierce JR. Investigation of accommodative and binocular function in dyslexia. 1996. The visual development process. Suchoff IB. 2010 Rawstron JA. O’Dell N. 1975. Optom Vis Sci. Viewpoints: nearpoint lens prescribing.29(1):4 –25 277.47(12):982–990 254.
265. Sharma P. ed. Drasdo N. J Learn Disabil. 1970.html?key BEHAVIOURAL. 1982. Evans BJ. Granet DB. Amos JF. Am J Optom Physiol Opt. 1986.icsi. learning. Goss DA. Greenspan SB.
266. National Joint Committee on Learning Disabilities. 1994. Accessed June 17.
270.aaopt. Sethi HS. Grisham JD.14(1):5–19 261. Mitchell GL. Validity and reliability of the revised convergence insufﬁciency symptom survey in children aged 9 to 18 years.org/ technology_assessment_reports_-_ active/ta_vision_therapy. Keddington J. 86(8):1015. et al.opticianonline. 71(3):100 –105 Beauchamp GR. 268.
264. Metha A. 1979. Drasdo N. TX: PRO-ED. The effect of accommodative deﬁciencies on the developmental level of perceptual skills. J Pediatr Ophthalmol Strabismus. Physiological effects of plus lens
263. Optom Vis Sci. Ophthalmic Physiol Opt. Joint organizational policy statement: vision. The efﬁcacy of visual therapy: accommodative disorders and non-strabismic anomalies of binocular vision. author reply 1016 –1017 274.50(9):1005–1011 Barry SH. 2010 Keogh BK. and dyslexia. WA: Special Child Publications 1969:45–57 259. American Optometric Association. J Am Optom Assoc. Inc. Am J Optom Physiol Opt. Effects of children’s nearpoint lenses upon body posture and performance. Foo KH. McBrien NA. 1985. 62(6):392–397 Keller JT.49(9):1047–1054 256. To the editor: treatment of convergence insufﬁciency in childhood: a current perspective. 11(4):435– 445 279. Available at: www. Apell RJ. Invest Ophthalmol Vis Sci. 1990. Vision training revisited. Tran WU.10(2):123–132 260. Seattle. Visual and Perceptual Aspects for the Achieving and Underachieving Child. Rouse MW. 1988. 124(2):287 276.
application.org/ about/position/index. Sinha A. J Learn Disabil. J Am Optom Assoc. Barrett B. 1985.42(2):82– 88
272. 2010 278. Available at: www. Wold RM.18(4):228 –236 American Academy of Optometry. 2005.57(2): 119 –125 257. Clin Exp Optom.net/Articles/2008/08/ 01/21616/Behave yourself. Fricke T. Accessed June 17. Low plus lenses and visual performance: a critical review.70(5):384 –391 258. Am J Optom Arch Am Acad Optom. Austin. In: Wold RM. Cochran CL. J Am Optom Assoc. 1986. 2005. Sheppard MM. J Behav Optom. 1979.asp. Ophthalmic Physiol Opt. Home exercises for convergence insufﬁciency in children. Efﬁcacy of treatment for visual information processing dysfunction and its effect on educational performance. Richards IL.html. Visual symptoms and reading performance. Sampson G. News: behave yourself.46:E-abstract 679 273. Optometric vision training. 2006. 267. Reading performance and low plus lenses. 1993. Technology assessment report: vision therapy. Hendrickson H. Saxena R. 2003. 2009. 1974. 1994: 49 –56
FROM THE AMERICAN ACADEMY OF PEDIATRICS
.80(12):832– 838 275. Issues in learning disabilities: assessment and diagnosis. Am J Optom Physiol Opt.
271. Ophthalmic Physiol Opt. Acad Ther.
269.77(1):121–124 Keogh BK. In: Collective Perspectives on Issues Affecting Learning Disabilities.253.56(11):667– 673 Wildsoet CF. Evans BJ. 2009.7(4):219 –231 Institute for Clinical Systems Improvement. Optician. Pediatrics. The perceptual effects of low-power plus lenses: studies of emmetropic observers. Hoffman LG. A critical evaluation of the evidence supporting the practice of behavioural vision therapy. Effectiveness of optometric vision therapy. Review of ophthalmic factors in dyslexia. Available at: www. Optometric vision training programs for children with learning disabilities. A systematic review of the applicability and efﬁcacy of eye exercises. 1978. Petito GT. Elder MJ.59(3):254 –262 255. Eye exercises and reading efﬁciency. Cook P. Accessed June 17. Heath MJ. Press LJ. Arch Ophthalmol. Pelland M.